THE  LIBRARY 

OF 

THE  UNIVERSITY 
OF  CALIFORNIA 

LOS  ANGELES 


MICHEI   LOUTFALLAH 


MEDICAL    OPHTHALMOSCOPY 


MAXUAL    AND    ATLAS 


OF 


MEDICAL  OPHTHALMOSCOPY 


BY 

W.     E.     GO  WEES,    M.D.,    F.E.S. 

FELLOW  OF   THE   BOYAL   COLLEGE   OF   PHYSICIANS 

CONSULTING   PHYSICIAN   TO   UNIVERSITY   COLLEGE    HOSPITAL 

PHYSICIAN   TO   THE   NATIONAL   HOSPITAL   FOB   THE   PABALYSED   AND    EPILEPTIC 


THIRD    EDITION 

Revised  throughout,  with  numerous  additions  and  additional  Illustrations 
EDITED   WITH   THE   ASSISTANCE  OF 

MAECUS  GUNN,  M.B.,  F.E.C.S. 

8UBGEON   TO   THE   BOYAL   LONDON  OPHTHALMIC   HOSPITAL,   HOOBFIBLDS 
OPHTHALMIC   SURGEON   TO   THE    NATIONAL   HOSPITAL   FOB   THE    PARALYSED   AND   EPILEPTIC 


PHILADELPHIA 

P.    BLAKISTON,    SON,    &    CO. 

1012,    WALNUT    STREET 
1890 


PREFACE    TO    THE    THIRD    EDITION. 


IN  preparing  this,  the  third  edition  of  "Medical  Ophthal- 
moscopy,"  the  whole  work  has  been  subjected  to  a  revision 
sufficiently  thorough  to  involve  additions  and  alterations  on 
almost  every  page  and  in  almost  every  paragraph.  An 
endeavour  has  been  made  to  embody  in  it  whatever  of  real 
value  has  been  added  to  our  knowledge,  since  the  appearance 
of  the  last  edition,  and  to  present  the  facts  to  the  reader  in 
the  aspect  that  they  bear  to  the  author,  as  viewed  in  the 
light  of  his  personal  experience.  Accordingly,  in  many 
parts  various  statements  have  been  not  only  added  to,  but 
recast  in  what  will  be  found,  it  is  hoped,  a  more  practical 
form. 

The  microscopic  figures  that  were  represented  on  photo- 
lithographic plates  in  preceding  editions  have  been  re- 
engraved  as  phototype  blocks,  and  appear,  in  this  edition, 
in  the  text  of  the  work,  in  connection  with  the  subjects  to 
which  they  refer.  Other  ophthalmoscopic  figures,  prepared 
in  the  same  way,  have  also  been  added.  The  cases  that 
were  described  in  full  in  previous  editions  have  served  their 
purpose,  and  the  extended  and  extending  use  of  the  ophthal- 
moscope in  medicine  has  made  such  facts  as  they  illustrated 
familiar  alike  to  physicians  and  students.  Brief  epitomes 
have,  therefore,  been  substituted,  and  placed  in  relation  to 
the  facts  that  the  case  illustrates.  Instead  of  these,  an 
account  is  given  of  the  most  convenient  procedure  in  draw- 
ing the  appearances  that  are  seen  in  the  eye.  It  is  hoped 

A    X 


VI  PREFACE. 

that  these  hints  may,  at  least,  have  the  effect  of  leading 
students  to  adopt  a  practice  that  will  be  found  to  be  of 
great  value,  even  beyond  the  subject  to  which  it  is 
applied. 

I  have  had,  in  this  edition,  the  help  of  Mr.  Marcus  Grunn, 
who  has  conferred  on  the  work  the  advantage  of  a  final 
revision,  and  has  also  superintended  its  passage  through  the 
press.  To  his  knowledge  and  care  the  reader  is  largely 
indebted. 

I  may  add  the  following  extract  from  the  preface  to  the 
first  edition,  published  in  1879 : — 

"  With  one  or  two  exceptions  all  the  cases  described  and 
figured  were  met  with  in  the  course  of  purely  medical  work, 
chiefly  at  University  College  Hospital,  and  at  the  National 
Hospital  for  the  Paralysed  and  Epileptic.  In  the  preparation 
of  the  illustrations,  great  care  has  been  taken  to  secure  the 
utmost  possible  exactness.  The  autotype  plates  are  repro- 
ductions of  sepia  drawings ;  and  this  method  has  been 
chiefly  employed  because  by  it  a  more  exact  representation 
of  delicate  pathological  appearances  can  be  obtained  than  by 
chromo-lithography.  This  method  has  also  the  advantage 
of  fixing  the  attention  on  the  changes  of  form,  rather  than 
upon  the  alterations  in  colour,  which,  important  as  they 
are,  very  often  mislead  the  inexperienced.  Chromo-litho- 
graphy has  been  employed  for  some  subjects  in  which  the 
changes  of  tint  are  of  predominant  importance.  It  is 
intended  that  the  autotype  plates  should  be  studied  by  the 
aid  of  the  descriptions  prefixed  to  them,  and  it  is  believed 
that,  thus  examined,  those  who  are  accustomed  to  the  use  of 
the  ophthalmoscope  will  not  miss  the  absent  colours.  With 
one  or  two  exceptions,"  specified  on  p.  305,  "  the  drawings 
were  all  made  by  the  direct  method  of  examination." 

W.  E.  GOWEBS. 


50,  QUEEN  AXNE  STREET, 
July,  1890. 


CONTENTS. 


PAGE 

INTRODUCTION  1 


PART  I. 

CHANGES  IN  THE  RETINAL  VESSELS  AND  OPTIC  NERVE  OF 
GENERAL  MEDICAL  SIGNIFICANCE. 

The  Retinal  Vessels  ...         ...         ...         ...  7 

Size           8 

Arrangement        ...         ...         ...         ...         ...         ...         ...         ...  12 

Course       13 

Structural  Changes         ...         ...         ...         ..           ...         ...         ...  13 

Aneurism ...         ...         ...         ...         ...         ...  15 

Circulation           ...         ...         ...         ...         ...         ...         ...         ...  18 

Pulsation          18 

Anaemia            ...         ...         ...         ...         ...         ...         ...         ...  22 

Hypersemia       ...         ...         ...         ...         ...         ...         ...         ...  24 

Haemorrhage    ...         ...         ...         ...         ...         ...         ...          ...  25 

Thrombosis      30 

Embolism         33 

The  Optic  Nerve        40 

Congestion            ...         ...         ...         ...         ...         ...  44 

Neuritis    ...         ...         ...         ...         ...         ...         ...         ...         ...  46 

Pathological  Anatomy          ...         ...         ...         ...         57 

Symptoms        ...         ...         ...         ...         ...         ...  67 

Causes ...         ...         ...         ...         ...         ...         ...  75 

Duration           ...         ...         ...         ...          ...         ...         ...         ...  76 

Relation  to  Encephalic  Disease       ...         ...         ...         78 

Varieties           92 

Diagnosis          ...         ...         ...         ...         94 

Prognosis          ...         ...         ...         ...         ...         ...  100 

Treatment         100 

Atrophy 102 

Characters         ...         ...         ...         ...         ...  103 

Causes  ...         ...         ...          ...         ...                     ...  110 

Pathological  Anatomy           ...         ...         ...         ...         ...         ...  116 

Symptoms        ...         ...         ...          119 


Vlll  CONTENTS. 


Atrophy  of  Optic  Nerve  (continued) — 

Diagnosis          ...         ...         ...         ...         ...         ...         ...         ...  128 

Prognosis          ...         ...         ...         ...         ...         ...         ...         ...  130 

Treatment 131 

The  Retina      132 

The  Choroid    .  135 


PART    II. 

Ol'HTHALMOSCOPIC    CHANGES   IX   SPECIAL   DISEASES. 

Diseases  and  Injuries  of  the  Nervous  System  : — 

Diseases  of  the  Brain        ...         ...         ...         ...         ...  137 

Anaemia  and  Hypenemia      ...         ...         ...         ...         ...         ...  137 

Inflammation  ...         ...         ...         ...         ...         ...         ...         ...  140 

Haemorrhage    ...         ...         .  .         ...         ...         ...         ...         ...  142 

Softening         ...         ...         ...         ...         ...         ...         ...         ...  146 

Embolic 146 

Thrombosis          '   .; 150 

Primary    ...         ...         ..          ...         ...         ...         ...         ...  154 

Abscess...         ...         ...         ...    '     ...         ...         ...         ...         ...  155 

Tumours  ...         ...      ....         ...         ...         ...         ...         ...  156 

Labio-glossal  Paralysis          ...         ...         ...         ...         ...         ...  168 

Intra-Cranial  Aneurism         ...         ...         ...          ..         ...         ...  168 

Internal  Hydrocephalus        ...         ...         ...         ...         ...         ...  169 

Diseases  of  the  Membranes  of  the  Brain  : — 

Meningeal  Growths        ...         ...         ...         ...         ...         ...         ...  170 

Meningitis  171 

Simple       172 

Tubercular  ...         ...         ...         ...         ...         ...         ...  173 

Syphilitic 177 

Haemorrhagic  Pachymeningitis  ...         ...         ...         ...  177 

Cerebro-Spinal 178 

Traumatic...         ...         ...         ...         ...         ...         ...         ...  178 

Diseases  of  the  Cranial  Bones         ...         ...         ...         ...         ...         ...  179 

Diseases  of  the  Orbit  180 

Injuries  to  the  Head 183 

Diseases  of  the  Nose...         ...         ...         ...         ...         ...         ...         ...  187 

Insolation  and  Heatstroke 188 

Diseases  of  the  Spinal  Cord  : — 

Inflammation       ...         ...         ...         ...         ...  189 

Sclerosis : — 

Posterior:  Locomotor  Ataxy  ...         ...         ...         ...         ...  190 

Lateral 195 

Insular 195 

Caries  of  the  Spine 196 

Injuries  to  the  Spine 197 


CONTENTS.  IX 

Functional  Diseases  of  ths  Nervous  System  : —  PAOK 

Exophthalmic  Goitre     198 

Chorea       198 

Neuralgia  and  Migraine           ...         ...         ...         ...         ...         ...  200 

Epilepsy 201 

Hysteria 204 

Insanity    ...         ...         ...         ...         ...          ...         ...         ...         ...  204 

General  Paralysis        ...         ...         ...         ...         ...         ...         ...  205 

Mania 207 

Melancholia      „         208 

Dementia          208 

Diseases  of  the  Urinary  System  : — 

•      Bright's  Disease 208 

Diabetes 227 

Diseases  of  the  Circulatory  System  : — 

Diseases  of  the  Heart    ...         ...         ...         ...         ...         ...         ...  232 

Diseases  of  the  Vessels ...         ...         ...         ...         ...         ...         ...  235 

Diseases  of  the  Blood  : — 

Plethora 236 

Anaemia : — 

Acute 236 

Chronic 242 

Pernicious         ...         ...         ...         ...         ...         ...         ...         ...  244 

Leucocythsemia    ...         ...         ...         ...         ...         ...         ...         ...  247 

Purpura 263 

Scurvy       ...         ...         ...         ...         ...         ...         ...         ...         ...  254 

Diseases  of  the  Lungs           ...         ...         ...         ...         ...         ...         ...  254 

Diseases  of  the  Digestive  Organs  ...         ...         ...         ...         ...         ...  255 

Diseases  of  the  Sexual  Organs       ...         ...         ...         ...         ...         ...  256 

Diseases  of  the  Skin...         ...         ...         ...         ...         ...      "...         ...  257 

Chronic  General  Diseases  : — 

Tuberculosis         ...         ...         ...         ...         •••         •••         •••         •••  257 

Morbid  Growths...         ...         ...         ...         •••         •••         •••         •••  263 

Syphilis 263 

Rheumatism         ...         ...         ...         •••         •••         •••         •••         •••  267 

Gout          267 

Lead  Poisoning  ...         ...         ...         •••         •••         •••         •••         •••  269 

Alcoholism           ...         ...         ...         •••         •••         •••         •••         •••  273 

Tobacco  Poisoning         275 

Quinine     ...         ...         ...         •••         •••         •••         •••         •••         •••  277 

Bisulphide  of  Carbon 278 

Other  Poisons      ...         ...         ...         •••         •••         •••         279 

Acute  General  Diseases  : — 

Typhus  Fever      279 

Typhoid  Fever 280 

Relapsing  Fever 

Measles      282 

Scarlet  Fever       282 

Variola                  284 


X  CONTENTS. 

Acute  General  Diseases  (continued) —  PAOK 

Acute  Rheumatism  ...  ...  ...  ...  ...  ...  ...  284 

Malarial  Fevers 284 

Erysipelas  ...  ...  ...  ...  ...  ...  288 

Diphtheria  ...  ...  ...  ...  ...  ...  289 

Parotitis 290 

Tonsillitis 290 

Whooping-Cough  ...  ...  •  ...  ...  ...  ...  ...  290 

Cholera  291 

Pyaemia  and  Septicaemia  ...  ...  ...  ...  ...  ...  291 

Ophthalmoscopic  Signs  of  Death 297 


APPENDIX. 
How  to  Sketch  the  Fundus  Oculi...  299 


CONTENTS.  XI 


DESCRIPTION   OF  THE  PLATES. 

PLATE  PAGE 

I. — Congestion     and     inflammation    of    optic    disc    in     cerebral 

embolism  and  tumour          ...         ...         ...         ...         ...  305 

II. — Atrophy  of  disc,  consecutive  and  simple,  in 'cerebral,  orbital, 

and  spinal  disease      ...         ...         ...         ...         ...         ...  307 

III. — Optic  neuritis   in    caries    of   bone,    chronic   meningitis,    and 

cerebral  tumour          ...         ...         ...          ...         ...         ...  310 

IV. — Optic  neuritis  in  syphilitic  disease  of  brain      ...         ...         ...  311 

V. — Optic  neuritis  in  cerebral  tumour           ...         ...         ...         ...  313 

VI. — Optic  neuritis  in  cerebral  tumour           ...         ...         ...         ...  315 

VII. — Optic    neuritis   in    syphilitic   disease   (unilateral)  ;     epilepsy, 

ansemia,  and  lead  poisoning           ...         ...         ...         ...  316 

VIII. — Neuro-retinitis  in  chlorosis           ...         ...         ...         ...         ...  318 

IX. — Retinal  haemorrhage,  optic  neuritis,  &c.,  in  kidney  disease  ...  319 

X. — Acute  and  chronic  retinal  changes  in  kidney  disease...         ...  320 

XI. — Retinal  changes  in  pernicious  ansemia  and  leucocytluemia    ...  320 
XII. — Retinal  changes,  aneurisms,  &c.,  in  kidney  disease  ;  embolism 

of  retinal  artery  in  cardiac  disease           ,,,         ...         ...  321 


MEDICAL    OPHTHALMOSCOPE 


INTKODUCTION. 

THE  ophthalmoscope  is  of  use  to  the  physician  because  it 
gives  information,  often  not  otherwise  obtainable,  regarding 
the  existence  or  nature  of  disease  elsewhere  than  in  the  eye. 
This  information  depends  upon  the  circumstance  that  we  have 
under  observation — 1.  The  termination  of  an  artery  and  the 
commencement  of  a  vein,  with  the  blood  circulating  in  each. 
2.  The  termination  of  a  nerve,  which,  from  its  close  prox- 
imity to  the  brain,  and  from  other  circumstances,  under- 
goes significant  changes  in  various  diseases  of  the  brain,  and 
in  affections  of  other  parts  of  the  nervous  system.  3.  A 
nervous  structure — the  retina,  and  a  vascular  structure — the 
choroid — which  also  suffer  in  a  peculiar  way  in  many  general 
diseases. 

For  the  efficient  use  of  the  ophthalmoscope  in  medical 
practice,  the  student  must  be  familiar  with  the  use  of  the 
instrument;  he  must  also  be  familiar  with  the  normal 
fundus  oculi,  with  the  changes  in  its  appearance  (congenital 
and  other)  that  are  of  no  significance,  and  also  with  those 
that  are  ocular  in  origin,  such  as  posterior  staphyloma, 
glaucomatous  excavation,  and  the  like.  An  acquaintance 
with  these  must  be  gained  from  the  ophthalmic  surgeon 
before  inferences  can  safely  be  drawn  regarding  the  signifi- 
cance of  other  alterations  met  with  in  various  diseases. 
The  following  pages  assume  the  possession  of  a  general 
knowledge  of  the  use  of  the  instrument,  but  a  few  words 

B 


2  MEDICAL    OPHTHALMOSCOPY. 

regarding  some  points  which  are  of  special  importance  may 
be  of  service. 

A  first  requisite  in  medical  ophthalmoscopy  is  familiarity 
with  the  direct  method  of  examination.  The  disc  is  then 
seen  magnified  many  times ;  and  this  method  may  show 
minute  changes  of  the  highest  significance,  which  cannot 
otherwise  be  detected,  or  the  true  nature  of  appearances 
which,  seen  by  the  indirect  method,  are  obscure.  But  both 
methods  should  always  be  employed.  Not  only  has  each 
its  special  advantage,  but  the  two  together  often  give 
information  which  neither  alone  affords. 

Another  requisite  is  skill  in  the  examination  without 
dilatation  of  the  pupil.  In  most  eyes  much  can  be  seen  with 
the  pupil  undilated — often  all  that  is  necessary,  and  almost 
always  enough  to  determine  whether  or  not  there  is  more 
to  be  learned  by  dilatation.  The  coincident  paralysis  of 
accommodation  is  a  source  of  annoyance,  and  is  especially 
resented  by  patients  when  there  is  no  disease  of  the  eye 
itself.  If  the  sight  has  not  been  previously  affected,  it  often 
happens  that  in  brain  diseases  there  is  a  subsequent  failure 
of  sight,  due  to  changes,  neuritis,  atrophy,  &c.,  which  after- 
wards progressed.  The  failure  of  sight  in  such  cases  is 
often  ascribed  by  the  patient,  not  unnaturally,  to  the  effect 
of  the  mydriatic.1  For  the  same  reasons  one  pupil  only 
should  be  dilated  at  a  time,  unless  the  sight  of  both  eyes  is 
already  impaired.  If  it  is  a  matter  of  indifference  which  is 
chosen,  an  eye,  the  sight  of  which  is  impaired,  should  be 
chosen  in  preference  to  the  other.  These  disadvantages 
have  been  lessened  by  the  use  of  other  mydriatics  than 
atropine,  or  by  using  eserine  when  the  examination  is  over, 
to  contract  the  dilated  pupil.  Homatropine,  however,  has 
largely  superseded  atropine  as  a  dilator,  since  the  paralysis 
of  accommodation  passes  off  in  a  few  hours,  and  the 

1  "  If  we  use  the  ophthalmoscope,  or  if  we  use  atropine,  or  if  we  apply  a 
blister  to  the  head,  or  adopt  any  new  kind  of  treatment,  the  patient  may 
blame  us  for  his  blindness,  if  he  saw  well  before  such  procedures.  A  patient 
who  reads  the  smallest  print  and  supposes  his  sight  to  be  good,  may  have 
double  optic  neuritis.  The  use  of  atropine  affects  his  sight  for  near  objects 


INTRODUCTION.  3 

dilatation  of  the  pupil  seldom  persists  more  than  a  day. 
Cocaine  is  likewise  a  useful  mydriatic,  on  account  of  the  short 
duration  of  its  effects,  and  from  the  facility  with  which  they 
yield  to  eserine.  Its  use  is  particularly  indicated  where 
there  is  any  danger  of  exciting  increased  tension  in  the  eye- 
ball by  ordinary  mydriatics. 

In  making  an  examination  with  the  ophthalmoscope,  it  is 
best  to  look  at  the  eye  first  from  a  distance,  in  order  to 
ascertain  whether  the  red  reflection  from  the  fundus  is  clear. 
This  at  once  gives  information  regarding  the  presence  or 
absence  of  opacity  of  the  lens  or  vitreous,  or  may  reveal 
iritic  adhesions — conditions  which  convey  important  informa- 
tion, and  explain  what  would  otherwise  be  a  puzzling 
obscurity  of  detail.  Next,  the  refraction  of  the  eye  should 
be  roughly  estimated  by  observing  if  the  vessels  of  the  retina 
can  be  distinctly  seen  from  a  distance,  and,  if  so,  whether 
they  move  in  the  same  direction  as  Ihe  observer's  head 
(hypennetropia) ,  or  in  the  opposite  direction  (myopia). 
The  knowledge  of  the  condition  of  the  eye  thus  gained  is  of 
much  importance,  since  in  myopia  the  details  of  the  fundus 
appear,  by  the  indirect  method,  small,  and  in  hypermetropia 
they  appear  large.  If  necessary,  the  refraction  may  be 
more  accurately  ascertained  by  the  use  of  a  refraction 
ophthalmoscope  :  the  lens  needed  to  correct  it,  if  the  observer's 
refraction  is  normal,  is  the  indication  of  the  degree  of  error. 

It  is  frequently  necessary  to  examine  patients  in  bed. 
The  indirect  method  of  examination  can  be  applied  as 
readily  to  a  patient  in  bed  as  to  one  sitting  on  a  chair,  the 

gravely,  and  if,  from  the  advance  of  the  neuritic  process,  what  I  may  call 
retinal  sight  fails  before  the  effect  of  the  atropine  has  passed  off,  he  very 
naturally  blames  us  for  the  subsequent  permanent  affection  of  his  sight.  A 
patient,  when  asked  how  long  his  sight  had  been  bad,  replied,  'Only  since 
the  drops  had  been  put  in.'  "We  must,  then,  when  we  discover  neuritis, 
sight  being  good,  tell  the  patient  that  his  eyes  are  not  really  good,  and  that 
we  are  anxious  about  his  sight.  Whether  we  give  this  warning  or  not,  we 
shall  be  blamed  by  an  unintelligent  patient  for  'tampering  with  his  eyes.' 
We  must,  however,  act  for  our  patient's  good,  regardless  of  selfish  con- 
siderations. In  very  many  cases  we  can  see  enough  for  diagnostic  purposes 
without  using  atropine." — Hughlings-Jackson,  Lectures  on  Optic  Neuritis, 
"  Med.  Times  and  Gaz.,"  September  16,  1871. 

B    2 


MEDICAL    OPHTHALMOSCOPY. 

most  convenient  place  for  the  light  being  on  the  pillow 
above  the  patient's  head.  Even  in  daylight  little  difficulty 
is  experienced  unless  the  pupil  is  small,  but  the  examination 
is  facilitated  by  a  screen  of  some  kind,  even  by  the  shade  of 
an  umbrella.  The  direct  method  presents  more  difficulty ; 
a  convenient  position  is  at  right  angles  to  the  patient,  with 
the  lamp  on  the  opposite  side  of  the  patient's  head. 

All  who  have  employed  the  ophthalmoscope  in  medical 
practice  will  agree  with  Hughlings-Jackson  in  urging  the 
routine  use  of  the  instrument  in  all  diseases  in  which 
ophthalmoscopic  changes  are,  even  occasionally,  met  with.  It 
often  happens  that  unexpected  information  is  gained  regard- 
ing the  nature  of  the  disease,  or  its  probable  consequences. 

It  has  been  remarked  that  the  medical  ophthalmoscopist 
should  possess  familiarity  with  those  changes  in  the  eye 
which  are  of  purely  ocular  significance.  It  is  of  equal 
importance  that  he  should  be  familiar  with  those  con- 
genital changes  in  the  eye  which  are  of  no  significance. 
Many  of  these  will  be  alluded  to  in  describing  the  morbid 
appearances  with  which  they  are  most  liable  to  be  confounded. 
One  or  two,  which  give  rise  to  special  trouble  to  the 
beginner,  may  be  here  briefly  mentioned.  One  of  these 
io  the  variation  in  the  colour  of  the  optic  disc.  It  has  been 
well  remarked  that  the  tint  of  the  optic  disc  may  vary  as 
much  as  the  tint  of  the  cheek  It  is  always  redder  in  the 
young  than  in  the  old.  In  the  latter  the  redness  has  often 
a  grey  tint  mingled  with  it.  In  the  young  the  tint  may 
even  be  scarcely  or  not  at  all  paler  than  that  of  the  adjacent 
choroid.  When  the  choroid  is  bright  in  tint,  the  apparent 
redness  of  the  disc  is  increased  by  indirect  examination  with 
a  wide  pupil  and  a  bright  light,  and  is  a  very  frequent 
source  not  only  of  error  in  diagnosis  but  of  scientific  mis- 
takes. It  is  the  sharpness  of  the  edge  of  the  disc  to  which 
attention  should  be  especially  directed. 

When  the  physiological  cup  is  very  large,  the  vascular 
portion  of  the  disc  is  confined  to  a  narrow  rim  at  the  side, 
often  much  narrower  than  that  shown  in  PI.  III.  1,  which 
represents  a  large  but  not  very  large  cup.  When  the  part  of 


INTRODUCTION.  O 

the  disc  occupied  by  the  nerve  fibres  is  reduced  to,  say,  one- 
half  of  that  shown  in  the  figure,  the  fibres  are  so  crowded 
together  that  the  choroidal  limit  is  often  less  distinct  than 
normal,  and  the  central  white  cup  may  be  mistaken  for  the 
disc,  the  edge  being  regarded  as  part  of  the  fundus.  Know- 
ledge of  this  danger,  however,  will  be  sufficient  to  prevent  an 
attentive  observer  from  falling  into  this  error ;  there  is  no 
confusion  on  direct  examination. 

White  patches  near  the  disc,  due  to  choroidal  atrophy  and 
to  opaque  nerve  fibres,  sometimes  present  puzzling  appear- 
ances (Fig.  1).  The  recognition  of  choroidal  atrophy  by 
the  greyish-white  tint  of  the  sclerotic,  by  the  pigment 
disturbance,  and  by  the  comparative  absence  of  change  in 
the  retinal  vessels,  is  usually  one  of  the  first  points 
learned.  Now  and  then  a  narrow  posterior  staphyloma 
may  surround,  or  almost  surround,  the  disc,  and  its  edge 
may  be  mistaken  for  the  edge  of  the  disc,  which  then  ap- 
pears white  with  a  red  centre,  an  appearance  with  which  I 
have  known  beginners  to  be  much  puzzled.  (It  is  well  to 
remember  that  posterior  staphyloma  may  be  seen  occasionally 


FKJ.  1. — OPAQUE  NERVE  FIBRE*, 
Surrounding  optic  disc,  and  concealing  the  vessels  in  that  neighbourhood. 


6  MEDICAL    OPHTHALMOSCOPY. 

in  hypermetropic  eyes,  as  well  as  in  the  myopic  eyes,  in 
which  it  is  so  common.) 

The  white  patches  of  opaque  nerve  fibres  (such  as  are 
shown  in  Fig.  1)  are  characterized  by  their  position, 
adjacent  to  the  disc ;  by  the  peculiar  shape  of  the  spot, 
which,  if  large,  follows  the  course  of  the  nerve  fibres ;  by 
the  partial  concealment  of  the  vessels;  the  feathery  edge; 
and  by  the  centre  of  the  disc  being  commonly  unconcealed. 
When  a  small  patch  lies  near,  but  separated  from  the  disc, 
the  resemblance  to  an  inflammatory  exudation  may  be  very 
close ;  the  characters  of  its  edge,  and  the  absence  of  other 
changes,  will  usually  enable  its  nature  to  be  recognized.1 

Peculiar  white  films  sometimes  lie  in  front  of  the  vessels 
on  the  disc,  looking  like  fragments  of  tissue  paper  or  white 
gauze,  and  allowing  the  vessels  behind  to  be  dimly  seen. 
These  may  be  left  by  a  pathological  process,  but  they  seem 
to  be  occasionally  congenital,  and  caused  by  an  undue 
development  of  tissue  at  the  back  of  the  vitreous.  When 
congenital,  the  vessels  are  merely  concealed ;  when  patholo- 
gical, they  are  constricted.  In  one  case  which  came  under 
my  observation,  a  congenital  film  extended  over  the  upper 
half  of  the  disc,  and  ended  on  one  side  in  a  reflected  edge. 

In  considering  what  may  be  learned  regarding  the  con- 
ditions of  the  general  system  by  observation  of  the  fundus 
oculi,  it  will  be  convenient  to  consider,  in  the  first  place, 
specially  those  intra-ocular  changes  which  are  of  general 
medical  significance,  viz.,  the  changes  in  the  vessels  and  the 
circulation  ;  the  changes,  inflammatory  and  atrophic,  in  the 
optic  nerve ;  and,  more  briefly,  the  alterations  in  the  retina 
and  choroid ;  and  secondly,  the  changes  which  are  met  with 
in  special  diseases  of  the  nervous  and  general  systems. 

1  It  is  of  great  importance  that  the  aspect  of  these  opaque  nerve  fibres 
should  be  familiar.  They  sometimes  give  rise  to  curious  errors  in  dia- 
gnosis. I  was  once  taken  to  see  a  patient  in  whom  a  large  and  charac- 
teristic patch  of  this  description  was  supposed  to  be  of  syphilitic  origin,  and 
to  indicate  that  a  cerebral  affection,  from  which  the  patient  was  suffering, 
was  of  the  same  nature. 


PART    I. 

CHANGES  IN  THE  RETINAL  VESSELS  AND  OPTIC 
NERVE  OF  GENERAL  MEDICAL  SIGNIFICANCE. 

THE   EETINAL   VESSELS. 

IN  no  other  structure  of  the  body  are  the  termination  of 
an  artery  and  the  commencement  of  a  vein  presented  to  view, 
and  information  regarding  the  general  state  of  the  vascular 
system  is  often  to  be  gained  from  an  inspection  of  their  size, 
texture,  and  the  conditions  of  the  circulation  within  them. 
It  must  be  remembered,  however,  that  the  vessels  there  seen 
are  of  very  small  size.  One  of  the  primary  divisions  of  the 
retioal  artery,  large  as  it  appears  to  direct  ophthalmoscopic 
examination,  is  in  reality  so  small  as  to  be  scarcely  visible  to 
the  unassisted  eye,  being  less  than  the  y^j-th  of  an  inch  in 
diameter,  and  the  smallest  vessels  visible  with  the  ophthal- 
moscope are  not  more  than  the  TtT^th  of  an  inch  in  diameter. 
But  these,  it  must  also  be  remembered,  are  considerably 
larger  than  capillaries.  The  retinal  capillaries  are  always 
invisible,  and,  away  from  the  optic  disc,  they  are  never  so 
numerous  as  to  occasion  any  recognizable  reddish  tint.  The 
red  colour  of  the  fundus  oculi  is  due  to  the  choroidal  vessels. 
A  second  point  to  be  remembered  is  that  the  red  lines 
spoken  of  as  the  retinal  arteries  or  veins  are  not  the  vessels 
themselves,  but  the  columns  of  blood  within  them.  The 
walls  of  the  vessels  are,  as  a  rule,  invisible  ;  they  are  always 
invisible  to  the  indirect  method  of  examination,  but  by  the 
direct  method  the  walls  of  the  larger  branches  may  be  some- 
times seen,  as  fine  white  translucent  lines  along  the  sides 
of  the  red  column  of  blood,  most  distinct  where  one  vessel 
passes  over  another.  They  are  best  seen  by  feeble  illumina- 


8  MEDICAL    OPHTHALMOSCOPY. 

tion,  and  especially  by  so  moving  the  mirror  as  to  render 
the  illumination  slight  and  oblique.  Sometimes,  as  will  be 
described  immediately,  the  outer  coat  of  the  vessel  is  so  thick 
as  to  be  very  conspicuous. 

The  paler  line  which  runs  down  the  centre  of  each  vessel 
is  probably  a  reflection  of  the  light  from  the  middle  of 
the  anterior  surface  of  the  column  of  blood.  It  is  distinct 
only  when  the  vessel  lies  in  a  plane  at  right  angles  to  the 
line  of  observation.  If  the  vessel,  in  consequence  of  an 
antero-posterior  curve,  ceases  to  be  in  a  plane  at  right  angles 
to  the  line  of  observation,  this  central  reflection  is  no  longer 
visible,  and  the  whole  width  of  the  vessel  is  of  the  same  dark 
colour  as  the  edge.  In  the  case  of  veins  this  change  is  very 
striking,  and  the  greater  amount  of  colour  makes  these  por- 
tions appear  darker  in  tint  than  the  rest.1  Many  examples 
of  this  will  be  found  in  the  appended  plates,  as  in  I.  4,  II. 
1,  III.  2,  4,  Y.  5,  6,  &c. 

STZE. — In  estimating  variations  in  size  of  the  retinal  vessels 
allowance  must  be  made  for  the  refraction,  i.e.,  magnifying 
power  of  the  eyeball,  remembering  that,  by  the  indirect 
method  of  examination,  in  myopic  eyes  the  details  appear 
small,  while  in  hypermetropic  eyes  the  objects  appear 
large.  In  the  direct  method  there  is  less  variation,  because, 
for  distinct  vision,  the  myopic  refraction  requires  correction 
by  a  lens.  The  apparent  size  of  the  disc  may  be  taken  as 
the  guide  to  the  amount  of  magnification.  There  is  no  very 
exact  method  of  estimating  the  absolute  size  of  the  vessels.2 
Sometimes,  however,  the  alteration  is  such  as  to  be  at  once 
evident  and  unquestionable.  A  little  custom  will  enable  a 
distinct  deviation  from  the  normal  to  be  readily  recognized. 

1  It  is  probable  that  such  portions  of  the  veins  are  especially  dark,  since, 
by  their  obliquity  to  the  line  of  vision,  this  passes  through  a  greater  amount 
of  blood  ;  the  light  reflection  from  behind  is  thus  lessened,  the  choroid  being 
much  paler  than  the  blood  in  the  veins.    Hence  the  change  in  tint  is  far  greater 
in  the  veins  than  in  the  arteries,  which  are  nearly  of  the  colour  of  the  choroid . 

2  If  a  wire  grating  is  fixed  in  front  of  the  light  used  for  the  direct  exami- 
nation, the  lines  of  the  wires  are  seen  on  the  fundus,  and  can  be  used  for 
measurement.    An  instrument  for  use  with  any  light,  with  wires  a  definite 
distance  apart,  is  described  in  previous  editions  of  this  book. 


CHANGES    IN    THE    RETINAL    VESSELS,    ETC.  9 

Special  attention  must  be  given  to  the  number  of  primary 
branches  of  the  vessel.  It  often  happens  that  veins  are  thought 
to  be  pathologically  large,  merely  because  they  are  few. 

The  relative  size  of  the  arteries  and  veins  can  be  observed 
with  more  exactness  than  their  absolute  size.  In  comparing 
the  two  it  is  usually  desirable  to  have  the  pupil  dilated, 
since  the  vessels  have  often  to  be  traced  for  a  consider- 
able distance  from  the  disc.  A  difficulty  arises  from  the 
fact  that  the  distribution  of  the  arteries  and  veins  corre- 
sponds approximately,  but  not  exactly.  Sometimes  two 
arterial  branches  accompany  one  venous  trunk  :  sometimes 
two  veins  accompany  one  artery.  But  in  each  eye  there  is 
usually  at  least  one  set  of  vessels  which  have  a  nearly 
identical  course  and  distribution,  run  side  by  side,  and  are 
available  for  comparison.  When  this  is  the  case  it  will  be 
found  that,  as  a  rule,  the  width  of  the  artery  is  about  two- 
thirds  or  three-quarters  that  of  the  vein.  An  alteration  in 
this  relation  may  arise  from  a  change  in  the  size  of  the 
artery  or  of  the  vein.  The  change  may  be  so  considerable 
that  its  nature  is  at  once  evident:  e.g.,  the  veins  may  be 
obviously  wider  than  normal,  or  the  artery  unquestionably 
narrower,  perhaps  visible  as  a  mere  line  even  by  the  direct 
method  of  examination  (PL  IX.  4,  XII.  2,  3).  When  the 
difference  is  slighter,  we  have  to  form  an  opinion  as  to  the 
change  on  which  it  depends  (whether  enlargement  of  vein  or 
diminution  of  artery)  by  our  knowledge  of  the  normal  size  of 
the  vessels — an  approximate  absolute  estimation.  A  little 
familiarity  with  the  appearance  of  the  vessels  under  normal 
conditions  will  commonly  enable  an  opinion  to  be  formed  as 
to  the  direction  in  which  the  change  exists. 

Equality  in  size  of  the  arterjr  and  vein  is  usually  due  to 
dilatation  of  the  artery.  When  the  relative  size  of  the  artery 
is  smaller  than  that  given  (f  or  §)  it  is  generally  due  to 
one  of  three  causes :  (1)  Venous  distension,  general  or 
local ;  (2)  Imperfect  filling  of  atonic  veins,  in  consequence 
of  which  they  are  flattened  at  right  angles  to  the  line  of 
observation  :  (3)  Contraction  of  the  arteries,  wkich  may  occur 
from  general  anaemia  (in  which  case  the  veins  are  large 


10  MEDICAL   OPHTHALMOSCOPY. 

and  atonic)  or  from  primary  arterial  contraction,  as  sometimes 
in  Bright's  disease  (in  which  tho  veins  also  are  commonly 
small),  or  from  local  obstruction  to  the  entrance  of  blood. 

Vein*. — Increased  width  of  the  veins,  therefore,  usually 
means  their  dilatation,  either  from  distension  or  from  atony, 
and  this  effect  is  commonly  uniform.  The  central  reflec- 
tion is  preserved  in  normal  characters.  A  varicose  condi- 
tion has  been  observed  in  a  few  cases,  but  is  of  doubtful 
significance.  A  remarkable  example  of  moniliform  dilata- 
tion has  been  figured  by  Liebreich  in  his  Atlas.  The 
distension  may  be  part  of  a  general  venous  fulness,  as  in 
cases  of  cardiac  or  pulmonary  obstruction ;  or  it  may  be 
of  local  origin.  Increased  intra-cranial  pressure  of  rapid 
development,  probably  causes  at  least  a  transient  increased 
fulness  of  the  retinal  veins.  When  of  slow  development, 
this  effect  is  rare,  in  consequence  of  the  anastomoses  of 
the  orbital  and  facial  veins.  Thus  the  veins  may  become 
large  in  acute,  and  not  in  chronic,  hydrocephalus.  The 
same  effect  may  be,  it  is  commonly  believed,  the  conse- 
quence of  distension  of  the  sheath  of  the  nerve,  and  of 
pressure  within  the  sclerotic  ring.  The  former  will  be 
considered  in  connection  with  neuritis ;  its  precise  influence 
is  difficult  to  estimate.  The  influence  of  the  rigid  sclerotic 
ring  cannot  be  regarded  as  demonstrated  beyond  question. 
It  is  said  to  intensify  the  effect  of  an  obstruction,  but  the 
evidence  is  hypothetical.  A  very  efficient  cause  of  disten- 
sion of  the  veins  is  their  compression  by  inflammatory 
products  within  the  optic  papilla.  Extreme  distension 
occurs  also  in  cases  of  thrombosis  in  the  central  vein  of 
the  retina  behind  the  globe. 

Increased  width  of  vein,  however,  does  not  necessarily 
imply  over-distension.  A  .vein  which  is  underfilled  may 
present  an  increased  width.  Usually,  if  the  quantity  of 
blood  within  a  vein  is  less  than  normal,  its  contractile  power 
enables  it  to  adapt  itself  to  the  diminished  bulk  of  the 
contents;  it  retains  its  cylindrical  form,  and  both  appears 
and  is  narrower.  But  in  states  of  anaemia,  the  atony  of  the 
vein  may  prevent  it  from  following  the  contents  in  calibre, 


CHANGES    IN    THE    RETINAL    VESSELS,    ETC.  11 

and  retaining  the  cylindrical  form.  It  may  then  have  a  more 
or  less  elliptical  lumen  (the  same  circumference  enclosing  a 
smaller  area  as  an  ellipse  than  as  a  circle),  and  in  the  retina, 
in  'consequence  of  the  intra-ocular  pressure,  the  flattening 
always  takes  place  in  the  plane  of  'the  retina,  at  right  angles 
to  the  line  of  vision,  and  the  vein  appears  of  undue  width. 
At  the  same  time  the  central  reflection  is  altered,  becoming 
commonly  indistinct,  but  sometimes  unduly  broad. 

This  condition  of  the  veins  is  seen  especially  in  extreme 
anaemia,  and  in  leucocythsemia,  as  in  the  accompanying 
figure  (see  also  PI.  XI.  1  and  2).  In  these  cases  the  arteries 
are  usually  smaller  than  normal,  and  so  the  contrast  between 
the  veins  and  arteries  is  enhanced. 

Diminution  in  the  size  of  the  veins  is  probably  always  the 
result  of  diminished  supply  of  blood. 

The  arteries  may  be  diminished  in  size  by  causes  similar  to 
those  which  lead  to  increased  width  of  the  veins,  such  as 
local  obstruction  to  the  entrance  of  blood.  The  latter  does 


FIG.  2. — BKOAD  RETINAL  VEINS  AND  NARROW  ARTERIES. 
From  a  case  of  leucocythseraia. 


12  MEDICAL   OPHTHALMOSCOPY. 

not  appear  to  result  from  general  intra-cranial  pressure, 
probably  because  of  the  resistance  afforded  by  the  strong 
walls  of  the  arteries.  It  is  doubtful  whether  effusion  into 
the  sheath  of  the  nerve  is  capable  of  diminishing  the  blood 
supply.  It  is  certain,  however,  that  the  pressure  of  in- 
flammatory products  within  the  papilla,  and  especially  their 
cicatricial  contraction,  may  cause  sufficient  constriction  of  the 
artery  to  lead  to  a  great  diminution  in  the  size  of  its 
branches.  Haemorrhage  around  the  vessel,  or  the  pressure 
of  growths,  may  have  the  same  effect.  In  no  condition, 
however,  does  the  diminution  in  the  size  of  the  vessel  reach 
such  a  degree  as  in  obstruction  by  embolism  (PI.  XII.  2 
and  3).  General  underfilling  of  the  arterial  system,  as  in 
cholera,  may  lead  to  a  great  diminution  in  the  size  of  the 
arteries,  their  strong  muscular  coat  maintaining  their  adapt- 
ation to  the  blood  within  them.  Mere  atony  does  not  cause 
the  increase  in  width  in  the  arteries  which  is  observed  in  the 
veins,  because  persistent  spasm  of  the  arteries  is  capable 
of  causing  a  permanent  diminution  in  their  size.  I  have 
repeatedly  observed  this  narrowing,  especially  in  cases  of 
Bright's  disease,  in  the  branches  beyond  the  disc.  It  reaches 
its  height  when  papillary  obstruction  is  superadded,  and 
then  a  degree  of  diminution  in  the  size  of  the  arteries  may 
be  seen,  rarely  if  ever  observed  in  obstruction  from  neuritis 
without  kidney  disease  (see  PI.  IX.  3  and  4).  Two  remark- 
able cases  observed  by  Ramorius  suggest  that  spasm  of  the 
retinal  arteries  may  be  a  consequence  of  malarial  poisoning 
(see  Part.  II,  "Malarial  Fevers"). 

Dilatation  of  the  arteries  is  due  to  a  vaeomotor  influence, 
and  is  conspicuous  in  some  cases  of  exophthalmic  goitre,  in 
which  over-action  of  the  heart  is  superadded.  It  is  doubtful 
whether  the  latter  cause  alone  ever  produces  visible  dilatation 
of  the  retinal  vessels. 

ARRANGEMENT. — The  anatomical  arrangement  of  the 
vessels  varies  considerably  in  different  individuals,  and  is, 
in  itself,  of  little  medical  significance.  The  number  of 
branches  into  which  the  primary  trunk  divides,  and  the 


CHANGES   IN    THE    RETINAL    VESSELS.    ETC.  13 

number  of  tributary  veins,  should  be  noted  in  connection 
with  the  apparent  size  of  the  vessels.  There  is  one  point, 
however,  which  does  possess  indirect  medical  significance. 
The  general  arrangement  of  the  vessels  in  the  two  eyes  is 
usually  similar.  Moreover,  similarity  in  vascular  arrange- 
ment may  be  inherited.  I  have  seen,  for  instance,  a 
peculiarity  in  the  course  of  the  retinal  vessels  in  a  mother 
exactly  reproduced  in  the  eye  of  her  daughter.  This  is  a 
striking  proof  of  the  transmission  of  vascular  arrangement 
in  general;  upon  this  depends  the  vascular  strain,  and,  in 
part  at  least,  the  occurrence  and  locality  of  vascular  degene- 
ration, and  even  of  vascular  rupture.  Thus,  inspection  of  the 
retinal  vessels  suggests  to  us  one  way  in  which  a  tendency 
to  cerebral  haemorrhage,  or  softening  from  atheroma,  may 
be  inherited. 

COURSE. — The  course  of  the  retinal  vessels  usually  pre- 
sents few  tortuosities,  and  those  which  exist  are  lateral, 
in  the  plane  of  the  retina.  A  considerable  increase  in 
tortuosity  may  be  associated  with  a  nsevus  of  the  adjacent 
part  of  the  skin.1  The  arteries  are  rather  more  tortuous  in 
hypermetropic  eyes  than  in  others.  When  the  vessels  are 
elongated  by  their  distension  or  atony,  these  lateral  curves 
are  exaggerated.  Antero-posterior  curves,  at  right  angles  to 
the  plane  of  the  retina,  are  indicated  by  the  change  in  the 
central  reflection  already  mentioned,  by  the  relative  displace- 
ment of  parts  at  different  levels  on  movements  of  the  ob- 
server's head,  and  sometimes  by  slight  obscuration  of  the 
vessel  at  the  lowest  point  of  the  curve.  They  always  indi- 
cate irregularities  in  the  retina  in  which  the  vessels  lie, 
commonly  swelling,  as  in  retinitis  and  retinal  oedema. 

STRUCTURAL  CHANGES. — Most  changes  in  the  tissue  of 
the  retinal  vessels  are  visible  only  to  the  direct  method  of 
examination.  The  commonest  change  is  an  increase  in  the 

1  See  Allen  Sturge  in  "  Clin.  Soc.  Trans.,"  vol.  xii.  1879,  p.  162.  For  cases 
of  idiopathic  tortuosity  of  retinal  vessels,  chiefly  affecting  the  veins,  sec  Benson, 
"Trans.  Ophth.  Soc.,"  vol.  ii.  p."  55;  Nettleship,  ibid.  p.  57;  Stephen 
Mackenzie,  ibid.  vol.  iii.  p.  101  ;  all  with  accompanying  drawings. 


14  MEDICAL   OPHTHALMOSCOPY- 

amount  of  tissue  of  the  wall,  especially  of  the  outer  coat, 
so  that  the  red  column  of  hlood  is  bounded  by  distinct 
white  lines.  Such  an  appearance  may  be  seen  in  most 
cases  in  the  healthy  fundus  near  the  centre  of  the  disc.  At 
the  point  at  which  the  vessels  emerge  from  the  disc  they 
are,  the  arteries  especially,  often  surrounded  by  this  white 
tissue,  sometimes  like  a  little  cloud  upon  them,  and  from  it 
prolongations  may  be  traced  along  the  chief  vessels.  When 
a  vessel  curves  over  the  edge  of  a  hollow  central  cup,  and  is 
seen  foreshortened,  the  white  tissue  of  the  wall  often  appears 
as  a  ring  around  the  blood-column.  When  a  disc  is  very  full 
coloured,  whether  normally  or  from  pathological  causes,  this 
white  tissue  is  rendered  by  contrast  very  conspicuous,  and 
may  easily  be  mistaken  for  a  pathological  condition  (PI.  I. 
2).  The  difficulty  is  increased  by  the  circumstance  that  it  is 
sometimes  a  morbid  appearance,  left  by  preceding  inflamma- 
tion. In  this  case,  however,  it  is  usually  accompanied  by 
distinct  constriction  of  the  vessels,  and  it  often  extends  along 
them  beyond  the  limits  of  the  disc.  It  has  been  thought 
that  this  tissue  is  sometimes  a  result  of  chronic  congestion  of 
the  disc,  insufficient  to  cause  such  an  "  exudation  "  as  shall 
distinctly  constrict  the  vessels.  This  is  possible,  but  the 
condition  is  so  common  without  either  congestion  or  in- 
flammation, that  the  presence  of  this  appearance  alone 
deserves  little  weight. 

An  undue  visibility  of  the  wall  of  the  vessel  is  said  to  be 
sometimes  caused  by  a  "  sclerosis  "  of  the  middle  coat,  a  con- 
dition of  thickening  of  the  coat  which,  under  the  microscope, 
bears  considerable  resemblance  to  the  appearance  presented 
by  lardaceous  degeneration. 

In  very  rare  cases,  there  is  such  a  thickening  of  the  outer 
coat  of  the  vessel,  or  an  increase  in  its  perivascular  sheath, 
that  the  tissue  is  visible,  not  merely  at  the  sides  of  the  vessel 
but  in  front  of  it,  concealing  the  red  reflection  from  the 
column  of  blood  within  it,  and  broad  white  bands  then  in- 
dicate the  position  and  course  of  the  vessel.  These  bands 
may  cease  suddenly,  so  that  lengths  of  red  blood  may  alter- 
nate with  the  white  bands.  This  condition  has  been  seen 


CHANGES    IN    THE    RETINAL    VESSELS,    ETC.  15 

in  Blight's  disease,  and  a  well-marked  example  is  shown  in 
PL  XII.  Fig.  1 ;  it  is  then  perhaps  similar  to  the  fibroid 
thickening  around  the  vessels  found  in  other  organs.  Some- 
times a  vessel  may  be  narrowed  at  the  affected  area ;  more 
commonly  its  calibre  is  unaffected.  In  the  case  figured  it  is 
seen  to  affect  the  arteries  only. 

In  most  inflammatory  conditions,  leucocytes  accumulate 
in  the  perivascular  sheaths,  and  in  the  retina  they  may  give 
rise  to  an  appearance  similar  to  that  just  described ;  this  has 
been  termed  "  perivasculitis."  According  to  Liebreich,  by  a 
careful  comparison  of  the  relative  width  of  the  column  of 
blood  and  of  the  white  band,  an  opinion  may  be  formed  of 
the  position  of  the  new  tissue,  whether  in  or  outside  the  wall 
of  the  vessel. 

Fatty  degeneration  of  the  vessels  is  sometimes  met  with 
as  a  senile  change,  or  after  inflammation.  It  affects  chiefly 
the  outer  coat,  but  has  only  been  recognized  by  microscopical 
examination,  and  there  is  doubt  whether  it  can  be  detected 
during  life. 

In  senile  fatty  degeneration  of  the  outer  coat  of  the  retinal 
vessels,  calcification  of  the  degenerated  portion  has  been 
found  after  death.  Actual  atheroma — i.e.,  endarteritis  de- 
formans — has  not,  so  far  as  I  am  aware,  been  found  in  the 
retinal  vessels  after  death ;  and  in  cases  in  which  it  is  well 
marked  elsewhere  I  have  often  looked  for  appearances  in  the 
retina  suggesting  its  existence,  but  without  success.  The 
retinal  arteries  are  far  below  the  size  in  which  atheromatous 
changes  are  common.  They  have  been  said  to  present  undue 
tortuosity  in  this  condition.1 

ANEURISM. — The  retinal  arteries  are  occasionally  the  seat 
of  aneurismal  dilatation.  Instances  of  it  are,  however,  rare, 
probably  on  account  of  the  support  which  is  afforded  to 
the  vessels  by  the  vitreous  humour.  When  aneurism  does 
occur,  its  significance  is  important,  because  in  no  other  way 
can  the  existence  of  aneurisms  on  vessels  so  small  as  those  of 

1  Concerning  so-called  "  Arteritis  obliterate,"  see  Furstner,  "  Centralbl. 
.f.  Nervenkr.,"  1882,  and  "Centralbl.  f.  Augenheilk.,"  1882,  p.  509. 


16  MEDICAL    OPHTHALMOSCOPY. 

the  retina  be  ascertained.  Dilatations  of  such  small  vessels 
are  commonly  not  associated  with  aneurisms  on  large  arteries, 
but  when  minute  aneurisms  exist  in  the  retina  they  almost 
always  exist  also  in  the  small  arteries  of  other  organs. 

Two  forms  of  aneurisms  have  been  observed  :  (1)  aneurisms 
of  some  size  on  the  primary  branches  of  the  central  artery 
on  the  disc :  (2)  miliary  aneurisms  of  the  arterial  twigs  in 
the  retina,  and  of  the  small  capillary  vessels. 

(1).  Very  few  instances  of  the  larger  aiieurismal  dilatations 
are  on  record.  One,  which  was  described  by  Sous,1  occupied 
the  upper  two-thirds  of  the  disc,  was  oval  in  form,  and  pre- 
sented distinct  pulsation,  synchronous  with  the  radial  pulse. 
The  arterial  branches  in  the  retina  were  very  narrow.  The 
patient  was  a  woman,  aged  sixty-four. 

(2) .  Miliary  aneurisms  were  found  post  mortem  by  Liou- 
ville,2  in  cases  in  which  cerebral  haemorrhage  resulted  from 
the  rupture  of  similar  aneurisms  in  the  brain.  The  largest 
was  about  the  size  of  a  pin's  head;  they  were  chiefly  situated 
at  the  branchings  of  the  vessels.  In  one  case  they  were 
widely  distributed  through  the  body,  being  found  on  the 
minute  arteries  of  the  pericardium,  mesentery,  &c.  They 
are  frequently  found  in  glaucomatous  eyes.  I  have  seen 
them  during  life  on  small  arteries  in  a  case  of  Bright's 
disease,  in  which  there  was  extensive  cardiac  and  vascular 
disease  (PI.  XII.  1).  The  lower  branch  of  the  artery  is  seen 
to  present  three  globular  dilatations  in  its  course,  the  third 
being  just  in  front  of  a  narrowed  segment.  The  general 
characters  of  these  aneurisms  are  there  seen.  The  central 
reflection  of  the  artery  is  widened  at  the  dilatation  in  accord- 
ance with  the  altered  surface  of  the  blood  within  the  vessel. 
The  wall  of  the  aneurism  is,  of  course,  invisible,  just  as  is 
the  wall  of  the  vessel  elsewhere  ;  its  existence  is  declared  by 
the  change  in  the  form  of  the  column  of  blood.  Bouchut3 
has  figured  two  examples  of  a  series  of  fusiform  dilatations 
of  the  retinal  arteries  in  general  paralysis  of  the  insane.  Hi& 
figures,  however,  suggest  considerable  exaggeration. 

1  "Ann.  d'Ocul.'  1865,  liii.  p.  241.       -  "Comptes  Rend."  1870,  Ixx.  p.  498. 
3  "Atlas  d'Ophtalmoseopie  Medicale  et  Cerebroscopie. " 


CHANGES    IN   THE    RETINAL    VESSELS,    ETC. 


17 


The  recognition  of  these  minute  arterial  aneurisms  presents 
little  difficulty.  The  contours  of  the  arteries  must  be  fol- 
lowed from  the  disc  to  the  ora  serrata  by  the  direct  method  of 
examination.  A  twist  in  a  vessel  may  cause  the  appearance  of 
a  local  bulging  which  may  look  like  an  aneurism,  but  a  care- 
ful examination  will  prevent  error.  Minute  hsemorrhages  in 
the  course  of  the  vessels  can  be  readily  distinguished  from 
aneurisms  by  the  irregularity  of  the  outline  of  the  clot. 
Aneurisms,  as  a  rule,  contain  fluid  blood,  and  present  a  bright 

central  reflection,  which 
is  absent  in  the  extra- 
vasation. It  must  be  re- 
membered, however,  that 
a  miliary  aneurism  has 
been  found  surrounded 
by  a  halo  of  extravasa- 
tion. The  centre  of  any 
haemorrhage  situated  at 
the  bifurcation  of  a  vessel 
should  therefore  be  care- 
fully scrutinized.  A  very 
rare  condition  has  been 
figured  by  Galezowski, 
which  might  easily  be 
mistaken  for  multiple 
sacculated  aneurisms ;  it 
consists  of  numerous  mi- 
nute secondary  glioma- 
tous  growths,  connected 
with  the  retinal  arteries. 
Some,  however,  were  of  large  size,  and  unconnected  with 
the  vessels,  and  none  presented  any  visible  reflection.1 

1  In  the  "  Trans.  Ophth.  Soc.,"  vols.  iii.  p.  108,  and  vi.  p.  336,  a  striking 
instance  of  aneurisnial  dilatations  of  retinal  arteries  and  veins  is  recorded  by 
Story  and  Benson.  The  case  affords  a  valuable  illustration  of  the  manner  in 
which  aneurisms  may  result  from  damage  done  to  the  walls  of  small  vessels, 
by  an  inflammation  of  the  walls  as  part  of  a  general  inflammation  of  the 
structures  in  which  the  vessels  lie.  The  history  of  the  case  is  unfortunately 
defective,  but  it  is  possible  that  the  primary  affection  of  the  retina  was 
syphilitic,  and  syphilis  is  known  to  be  a  cause  of  aneurisms  of  the  cerebral 
arteries. 


FIG.  3.— CAPILLARY  ANKUKISMS,  AND 

VARICOSE  CAPILLAUIE.S. 
a — e  From  a  case  of  diabetes  with  retinal 
haemorrhages  (from  preparations  by  Mr. 
Nettleship).  At  a,  b,  and  e  the  aneurisms 
are  situated  laterally,  at  c  in  the  course 
of  a  capillary,  and  at  d  at  the  bifurca- 
tion of  a  vessel  (  x  150).  /,  Varicose 
capillaries  from  a  case  of  Bright's  dis- 
ease (  x  150). 


18  MEDICAL   OPHTHALMOSCOPY. 

The  retinal  capillaries  may  present  aneurism al  dilatations 
sacculated  in  form,  and  also  varicose  dilatation.  Examples 
of  these  are  represented  in  Fig.  -J,  from  a  case  of  glycosiiria 
described  by  Dr.  Stephen  Mackenzie.1  Haemorrhages  into  the 
retina  and  vitreous  were  observed  during  life.  Capillary 
aneurisms,  from  a  case  of  Bright's  disease,  are  also  shown  in 
the  same  figure. 

CHANGES  IN  THE  CIRCULATION. 

The  central  artery  of  the  retina  brings  blood  to  the  eye 
from  within  the  cranial  cavity  ;  the  blood  comes  from  an 
artery  which  also  supplies  part  of  the  cerebrum  and  me- 
ninges  :  the  retinal  vein  returns  the  blood  chiefly  to  a  cranial 
sinus.  Hence  the  intra-ocular  circulation  has  been  regarded 
as  a  portion  of  the  cerebral  circulation,  as  participating  in 
the  same  influences,  and  presenting  the  same  modifications. 
This  is,  no  doubt,  true  to  some  extent.  At  the  same  time 
it  is  probable  that  the  consequences  of  the  common  origin  of 
the  cerebral  and  ocular  blood- supply  have  been  exaggerated. 
It  is  important  to  bear  in  mind  that  the  intra-ocular  circula- 
tion is  peculiar  in  its  rigid  enclosure  in  a  small  chamber, 
in  which  it  is  always  exposed  to  a  certain  amount  of  elastic 
pressure.  Moreover,  the  anastomosis  between  the  orbital  and 
facial  veins  tends  to  prevent  a  close  correspondence  between 
the  intra-cranial  and  intra-ocular  veins.  The  relation  be- 
tween the  cerebral  and  ocular  circulation  is  unquestionably 
greatly  modified  by  these  and  other  influences. 

PULSATION. — Arterial. — As  a  rule,  before  reaching  arteries 
so  small  as  those  of  the  retina,  the  pulse- wave  has  become  so 
feeble,  the  current  so  equable,  that  visible  pulsation  can  no 
longer  be  perceived.  The  pulsation  is  also  diminished  by 
the  normal  pressure  within  the  eye  ;  this,  in  giving  support  to 
the  retinal  vessels,  necessarily  lessens  their  distension.  If, 
however,  the  current  be  rendered  less  equable  by  an  increase 
in  the  disproportion  between  the  continuous  flow  and  the 
intermitting  wave,  arterial  pulsation  may  sometimes  be 
1  "Ophth.  Hosp.  Rep.,"  December,  1877. 


CHANGES    IN    THE    RETINAL    VESSELS PULSATION.  19 

perceived.  Locally,  this  disproportion  may  be  increased  by 
a  Change  in  the  intra-ocular  tension  :  thus  a  temporary 
distinct  arterial  pulsation  usually  results  from  the  artificial 
production  of  increased  tension  by  pressure  on  the  globe 
with  the  finger.  Again,  a  diminution  of  intra-ocular  tension 
may,  perhaps,  sometimes  occasion  visible  arterial  pulsation.1 

In  conditions  of  acute  anaemia  from  haemorrhage,  the 
continuous  flow  of  blood  into  the  small  vessels  may  be 
feeble,  and  the  pulse-wave  then  becomes  distinctly  visible.2 
But  it  is  especially  when  the  pulse-wave  is  increased  in 
strength  and  suddenness  that  it  becomes  visible  in  the  retinal 
arteries.  This  increase  is  developed  in  aortic  regurgitation, 
and  in  that  condition  spontaneous  pulsation  of  the  retinal 
arteries  is  especially  frequent,  as  Quincke,3  Becker,4  and  Fitz- 
gerald,5 first  pointed  out.  It  is  more  distinct,  the  greater 
is  the  hypertrophy  of  the  left  ventricle,  and  is  absent  only 
when  the  heart  is  greatly  weakened,  when  much  aortic  con- 
striction coexists,  or  the  amount  of  regurgitation  is  small.  It 
may  be  seen  best  in  the  vessels  on  the  disc,  but  can  often  be 
recognized  far  towards  the  periphery  of  the  retina,  and  in 
this  latter  respect  is  distinguished  from  the  pulsation  due  to 
mere  increase  of  intra-ocular  tension.  It  consists,  like  the 
pulsation  of  other  vessels,  in  a  widening  and  an  elongation. 
The  widening  is  best  seen  behind  a  division  at  a  considerable 
angle,  and  is  best  recognized  by  attending  to  the  central  re- 
flection. The  elongation  of  the  vessel  is  best  seen  where  an 
artery  lies  in  an  S  curve,  especially  towards  the  periphery, 
or  when  it  forms  a  curve  along  the  edge  of  the  disc  (Becker). 

1  Such  a  diminution  is  said  sometimes  to  occur  in  the  course  of  typhoid 
fever,  and  pulsation  has  been  observed  in  the  retinal  artery  in  this  disease  by 
Schmall.     See  "Retinal  Circulation  and  Arterial  Pulse  in  General  Disease," 
"  V.  Graefe's  Archiv.,"  xxxiv.  1,  p.  37,  and  "  Oph.  Rev.,"  1888,  p.  268. 

2  An  arterial  pulse  has  also  frequently  been  observed  by  Schmall  in  cases 
of  chlorosis.     Here,  as  in  anaemia  generally,  Rahlmann  ascribes  the  pulsation 
to  hydrsemia,  but  Schmall  considers  it  due  to  "  a  certain  amount  of  cardiac 
contraction,  combined  with  sudden  relaxation  of  the  heart  muscles,  occurring 
in  certain  states  of  low  arterial  tension."     (Op.  cit.) 

3  "  Berlin  Klin.  Wochenschr. , "  1868,  No.  34,  and  1870,  No.  21. 

4  "Arch.  f.  Ophth.,"xviii.  206—296. 

5  "British  Med.  Journal,"  Dec.  23,  1871,  p.  723.     Dr.  Stephen  Mackenzie 
has  also  recorded  several  cases  ("  Med.  Times  and  Gaz. ,"  1875,  vol.  i.). 


20  MEDICAL   OPHTHALMOSCOPY. 

In  a  case  of  supposed  aneurism  of  the  arch  of  the  aorta,  Becker 
found  marked  pulsation  in  the  left  eye,  while  in  the  right 
only  a  trace  of  pulsation  could  with  difficulty  be  detected. 

Pulsation  in  an  extreme  degree  appears  to  be  sometimes 
physiological.  It  was  present  in  a  man  under  my  care  who 
had  also  a  very  faint  diastolic  basic  murmur  but  no  hyper- 
trophy or  dilatation  of  the  left  ventricle,  so  that  there  was 
certainly  not  enough  aortic  regurgitation  to  account  for  the 
pulsation.  A  capillary  pulse  could  readily  be  obtained  in 
the  forehead.  The  increased  pulsation  seemed  to  be  in  the 
small  arteries  only,  since  at  the  wrist,  even  when  the  arm  was 
raised,  the  artery  had  the  normal  pulse-characters.  In  the 
eye,  pulsation  was  conspicuous  in  both  arteries  and  veins, 
and  slight  pressure  on  the  globe  increased  it  to  such  an  extent 
that  some  veins  on  the  disc,  of  full  size  in  the  diastole,  actually 
disappeared  at  each  systole.  Moreover,  the  diastole  of  the 
arteries  corresponded  to  the  systole  of  the  veins,  and  the 
pulsation  in  the  latter  must  therefore  have  been  due  to  the 
mechanism  to  be  presently  mentioned. 

Capillary  pulsation  has  been  described  in  aortic  regurgita- 
tion— a  pulsatile  redness  of  the  disc — due  to  the  intermitting 
distension  of  the  capillaries  in  consequence  of  the  great  fall 
of  pressure  between  the  successive  pulses.  Such  an  appear- 
ance is,  however,  very  rare,  and  can  seldom  be  detected  even 
when  a  pulsatile  blush  is  visible  on  the  forehead. 

Tenons. — Pulsation  in  the  retinal  veins  may  frequently 
be  observed  as  a  normal  condition,  chiefly  in  the  large 
branches  upon  the  optic  disc,1  especially  where  the  veins 
curve  down  the  sides  of  the  cup.  It  is  almost  constant  in 
aortic  regurgitation,  and  is  much  more  frequently  con- 
spicuous in  this  disease  than  the  arterial  pulse. 

Several  explanations  have  been  given  of  the  venous 
pulse.  The  theory  which  is,  perhaps,  the  most  plausible 
explains  the  pulsation  by  supposing  that  where  the  artery 
and  vein  are  near  together,  in  the  sclerotic  ring  or  optic 

1  Messrs.  Lang  &  Barrett  found  a  venous  pulse  on  the  disc  in  73 '8  per  cent, 
of  the  eyes  examined  by  them  at  Moorfields.  "  Ophth.  Hosp.  Rep.,"  vol.  xii. 
p.  60. 


CHANGES   IN    THE    RETINAL    VESSELS PULSATION.  21 

nerve,  the  arterial  distension  compresses  the  vein  and 
causes  a  temporary  obstruction  to  the  return  of  the  blood. 
The  nearer  the  two  are,  the  more  readily  will  this  effect  be 
produced,  and  the  more  slight  a  morbid  increase  needs  to  be 
for  the  artery  to  transmit  an  inverse  pulsation  to  the  vein. 

Coccius  suggested  that  the  venous  pulse  depends  directly 
on  the  intra-ocular  tension,  being  analogous  to  that  whicli 
occurs  in  glaucoma,  and  may  be  produced  artificially  by 
pressure  on  the  eyeball.  Every  time  the  pulse- wave 
reaches  the  intra-ocular  arteries,  their  distension  causes  a 
sudden  increase  in  the  intra-ocular  tension,  which  com- 
presses most  the  thinner  walled  veins,  and  lessens  the 
amount  of  blood  in  them.  Hence  the  contraction  of  the 
veins  should  correspond  to  the  arterial  diastole,  to  the 
pulse-wave,  and  the  dilatation  of  the  veins  to  the  arterial 
systole,  to  the  interval  between  the  pulse-waves.  As  a 
rule,  however,  this  is  not  the  case  :  the  distension  of  the 
veins  nearly  corresponds  in  time  with  the  arterial  dis- 
tension. Hence,  Stellwag  von  Carion  imagined  that  the 
extension  of  the  sclerotic  by  the  increased  intra-ocular 
pressure  at  each  pulse  stretches  the  lamina  cribrosa,  and 
narrows  its  meshes  so  as  to  compress  the  vein. 

According  to  Donders,  the  increased  intra-ocular  pressure 
acts  directly  on  the  venous  trunks  in  the  optic  disc, 
hindering  the  return  of  blood.  Similarly,  Jacobi,  on  the 
grounds  of  the  common  limitation  of  pulsation  to  the 
papilla,  suggests  that  the  increased  intra-ocular  pressure, 
depressing  the  papilla,  augments  the  curve  of  the  veins, 
and  so  causes  a  sudden  obstruction  to  the  circulation 
through  them. 

Helfreich,  on  the  other  hand,  considers  that  the  venous  pulse 
is  due  to  a  pulse  in  the  cerebral  veins,  grounding  his  opinion 
on  experiments  that  show  the  tension  in  these  to  be  high, 
and  that  they  pulsate.  He  states  that  the  venous  pulsation 
is  synchronous  with  the  cardiac  diastole,  and  that  it  is  seen 
only  on  the  disc,  because  of  the  firmer  support  of  the  veins 
away  from  the  disc.1  It  has,  however,  been  mentioned 

1  Ophtk  Congress,  Heidelberg,  1882,  and  "Ophth.  Review,"  1882, 
p.  408. 


22  MEDICAL   OPHTHALMOSCOPY. 

(p.  18)  that  the  physical  conditions  in  the  eye  are  not 
exactly  similar  to  those  in  the  hrain.  Helfreich's  theory 
seems  to  account  for  the  coincidence  of  arterial  swelling 
and  venous  swelling,  but  so  also  does  the  juxtaposition  of 
the  arteries  and  veins  within  the  sclerotic  ring  mentioned 
above.  If  Helfreich's  theory  be  correct,  should  not  the 
pulsation  be  an  invariable  thing  ? 

Putnam  and  Wadsworth  (of  Boston,  U.S.A.)  have 
described1  an  intermitting  variation  in  size  of  the  retinal 
veins,  occurring  independently  of  the  pulsation,  synchronous 
with  the  heart's  action,  and  having  a  period  of  about 
five  respirations,  i.e.,  about  that  of  the  variations  in  arterial 
tension  found  to  occur  in  animals.  Their  observations  have 
not  yet  been  confirmed. 

ANAEMIA  OF  THE  RETINAL  VESSELS  may  be  part  of  general 
anaemia,  or  may  be  due  to  local  pressure  upon  the  artery, 
and  transient  anaemia  is  probably  sometimes  due  to  the 
vasomotor  nerves. 

When  due  to  local  causes  ("  retinal  ischaemia "  of  the 
Germans)  there  is  usually  simultaneous  pressure  on  the 
retinal  vein,  which  runs  side  by  side  with  the  artery.  The 
arteries  are  then  unduly  narrowed ;  whether  the  veins  are 
distended  or  not  depends  on  the  rapidity  or  slowness  with 
which  the  obstruction  is  developed.  This  condition  is 
constantly  seen  during  the  contraction  of  inflammatory 
tissue  in  the  papilla.  In  rare  cases,  in  which  the 
pressure  is  on  the  artery  immediately  after  its  entrance 
into  the  optic  nerve,  and  behind  the  vein,  which  enters  a 
little  in  front  of  the  artery,  the  arteries  may  be  narrowed 
without  any  distension  of  the  veins. 

Spasm  of  the  retinal  vessels  has  been  supposed  to  occur 
in  epilepsy,  and  also  to  be  the  cause  of  "  retinal  epi- 
lepsy," i.e.,  epileptiform  amaurosis.  I  have  examined  the 
retina  in  many  cases  of  epilepsy  immediately  after  fits 
without  observing  any  marked  change  in  the  arteries. 
During  several  epileptiform  convulsions,  I  have  kept  an 
artery  and  vein  in  view  throughout  the  fit,  by  the  direct 
1  "Journal  of  Nervous  and  Mental  Disease,"  October,  1878. 


CHANGES    IN    THE    RETINAL    VESSELS ANAEMIA.  23 

method  of  examination,  but  have  seen   no  change  in   the 
artery.     The  vein  was  distended  during  the  cyaiiotic  stage. 

General  defective  blood-supply  is  much  less  evident  in  the 
vessels  of  the  eye  than  elsewhere  :  probably  because  the 
intra-ocular  tension  effects  a  regulation  of  the  size  of  the 
retinal  vessels  (Donders) .  Loss  of  blood,  for  instance,  causes 
but  a  slight  change  in  the  retinal  vessels,  except  an  increased 
disproportion  between  the  arteries  and  the  veins,  due  in  part 
to  contraction  of  the  arteries,  and  in  part  to  atony  and 
flattening  of  the  underfilled  veins.  The  effect  of  haemor- 
rhage on  the  size  of  the  vessels  soon  passes  off,  because  the 
volume  of  the  blood  is  quickly  reproduced  by  the  passage 
into,  and  retention  in  it,  of  liquid  from  the  tissues  and 
alimentary  canal.1  A  similar  condition  of  the  retinal  vessels 
to  that  seen  in  acute  anosmia  was  observed  by  v.  Grraefe  in 
cholera.  During  the  stage  of  collapse  the  arteries  became 
narrow,  the  veins  dark,  but  of  normal  width.  Spontaneous 
pulsation  appeared  in  the  arteries,  and  was  attributed  to  cardiac 
weakness,  but  may,  perhaps,  have  been  due  to  the  diminution 
of  the  volume  of  the  blood,  rendering  the  amount  ejected 
from  the  left  ventricle  at  each  systole  so  'small  that  the  shock 
(pulse- wave)  predominated  over  the  movement  of  the  blood. 

The  acute  cerebral  anaemia  of  syncope  is  probably  attended 
by  a  similar  condition  of  the  retina,  and  to  it  the  transient 
blindness  which  sometimes  succeeds  syncope  may  be  due. 

Conditions  of  general  defective  blood-supply  render  the 
disc  paler,  but  the  variations  in  the  tint  of  the  disc,  under 
physiological  conditions,  are  so  great  that  it  is  only  by  com- 
parison of  the  state  of  the  disc  with  its  appearance  in  the 
same  patient  at  another  time,  that  any  information  can  be 
gained  from  it.  The  other  eye  is  usually  affected  in  the 
same  degree,  and  is  not,  therefore,  available  for  comparison. 

1  In  some  observations  on  the  effect  of  venesection  in  the  corpuscular 
richness  of  the  Llood,  kindly  made  for  me  by  Mr.  W.  S.  Tuke,  on  some 
patients  of  Mr.  Wharton  Jones,  it  was  found  that  the  fall  in  the  number  of 
blood-corpuscles  indicating  the  dilution  of  the  circulating  blood  to  reproduce 
its  volume,  took  place  in  the  course  of  an  hour.  It  was  found  also  that  the 
fall  was  greater  than  the  amount  of  blood  lost  could  account  for — i.e.,  that 
the  hydrsemia  became  for  a  time  excessive,  a  fact  which  may  account  for  the 
reputed  influence  of  slight,  quick  loss  of  blood. 


24  MEDICAL    OPHTHALMOSCOPY. 

HYPERJEMIA  OF  THE  RETINAL  VESSELS. — (A.)  Active  Con- 
gestion.— Apart  from  the  active  congestion  of  commencing 
inflammation  and  of  purely  ocular  conditions,  such  as  refrac- 
tive asthenopia,  and  exposure  to  excessive  light,  &c.  (which 
are  not  considered  here),  an  increased  supply  of  blood  to 
the  retina  may  be  due  to  whatever  causes  an  overfilling  of 
the  whole  or  part  of  the  arterial  system  of  which  the  retinal 
artery  forms  part.  Of  these,  excited  action  of  the  heart  is 
the  most  potent.  The  retinal  arteries  may  be  seen  to  be 
large,  and  sometimes,  though  rarely,  to  pulsate,  and  the 
communicated  pulsation  in  the  retinal  veins  may  also, 
commonly,  be  observed.  When  the  overaction  is  long- 
continued,  haemorrhages  may  occur.  A  similar  overfilling 
may  occur  from  obstruction  in  another  region  of  the  internal 
carotid.  Dilatation  of  the  arteries,  as  in  exophthalmic  goitre, 
may  also  cause  active  hyperaemia. 

(B.)  Passive  Congestion. — Passive  congestion  of  the  retinal 
vessels  may  occur  from  local  or  general  causes.  The  causes 
of  local  obstruction  to  the  return  of  blood  from  the  eye  are, 
for  the  most  part,  the  same  as  those  of  local  arterial  anemia. 
The  most  intense  passive  congestion  ever  seen  is  met  with  in 
thrombosis  of  the  retinal  vein.  Pressure  on  the  cavernous 
sinus  only  causes  transient  passive  congestion  of  the  retinal 
veins,  on  account  of  the  free  connection  of  the  orbital  and 
facial  twigs.  Passive  congestion  from  general  causes  is  very 
common,  and  results  from  whatever  hinders  the  return  of  the 
blood  from  the  head,  or  obstructs  the  circulation  through  the 
chest.  The  congestion  of  the  eye  is  thus  part  of  a  cephalic 
congestion,  or  of  a  general  venous  stasis.  The  former  com- 
monly results  from  pressure  on  the  jugular  or  innominate 
veins.  The  general  congestion  is  the  result  of  some  pul- 
monary or  cardiac  obstruction,  acute  or  chronic.  The  com- 
mon acute  causes  are — cough,  effort,  and  an  epileptic  fit. 
The  ophthalmoscope  shows  the  retinal  veins  in  these  condi- 
tions to  be  greatly  distended.  Unless,  however,  there  is  also 
disease  of  vessels,  haemorrhages  rarely  occur,  no  doubt  in 
consequence  of  the  support  afforded  to  the  vessel  by  the 
vitreous  humour.  The  intra-ocular  tension,  and  therefore 


CHANGES    IN    THE    RETINAL   VESSELS — HAEMORRHAGE.       20 

the  external  support,  is  probably  augmented  during  these 
conditions  of  increased  strain,  in  consequence  of  the  fulness 
•of  the  capillary  vessels.  It  is  true  that  the  most  intense  con- 
gestion, such  as  that  of  suffocation,  sufficient  to  cause  death, 
does  usually  lead  to  retinal  haemorrhages,  but  minor  degrees 
of  congestion  rarely  do  so  unless  the  vessels  are  diseased.  It 
is  very  common,  for  instance,  for  a  violent  cough,  or  an 
intense  asphyxial  stage  of  an  epileptic  fit,  to  cause  rupture  of 
a  subconjunctival  vessel,  and  a  consequent  extravasation,  but 
it  is  extremely  rare  for  any  retinal  vessel  to  give  way.  I 
have  often,  in  such  cases  of  epilepsy,  searched  the  retina  for 
extravasation,  but  the  search  has  always  been  unsuccessful. 
In  whooping-cough,  retinal  extravasations  have  been  seen 
only  in  extremely  rare  cases. 

Chronic  general  causes  of  passive  congestion  are  chiefly 
heart  disease  (especially  mitral)  and  emphysema  of  the 
lungs.  In  the  general  venous  distension  of  congenital  heart 
disease — cyanosis — the  retinal  vessels  participate,  often  con- 
spicuously. The  venous  distension  may  be  extreme,  and  may 
be  accompanied  by  normal  arteries,  or  the  arteries  may  be 
also  large.  The  blood  in  the  arteries  and  veins  may  be 
abnormally  dark.  Sometimes  the  retinal  tissues  are  thickened. 
The  congestion  from  emphysema  of  the  lungs,  and  from 
dilatation  of  the  right  heart,  is  also  often  very  marked. 
The  retinal  veins  become  much  distended  and  tortuous, 
and  the  smaller  branches,  ordinarily  invisible,  may  become 
conspicuous. 

HJEMORRHAGE. — Rupture  of  retinal  vessels  and  consequent 
extravasations  of  blood  are  very  common  in  many  morbid 
states,  and  are  frequently  of  important  general  significance. 
They  may  occur  as  part  of  inflammation  of  the  retina,  and 
such  cases  will  be  considered  subsequently.  More  frequently 
they  are  dependent  directly  on  general  conditions,  or  on  retinal 
disease  consequent  on  general  conditions. 

They  vary  much  in  size,  number,  position,  and  aspect. 
They  may  be  so  small  as  to  be  visible  only  as  a  spot  or  line 
on  direct  examination,  or  they  may  be  three  or  four  times 


26  MEDICAL    OPHTHALMOSCOPY. 

the  diameter  of  the  optic  disc.  There  may  be  only  one  or 
two,  or  innumerable  extravasations  may  exist  over  the  whole 
fundus.  When  few  they  are  commonly  seated  near  the  disc 
or  in  the  neighbourhood  of  the  macula  lutea;  when  numerous, 
the  largest  are  often  situated  near  the  macula.  They  often 
follow  the  course  of  vessels,  especially  the  veins,  but  not 
unfrequently  the  arteries.  Their  shape  and  aspect  depend 
very  much  on  their  position  in  the  substance  of  the  retina , 
The  commonest  seat  is  in  the  layer  of  nerve  fibres.  The  fibres 
are  separated,  not  torn,  by  the  extravasation,  and  the  blood 
lies  between  them,  extending  along  their  course  in  the  direc- 
tion of  least  resistance.  Hence  the  smaller  ha?morrhage& 
are  linear,  the  larger  striated  in  part  or  altogether,  and 
they  often  radiate  from  the  disc.  Such  hcemorrhages  are 
shown  in  PL  Y.  4,  YI.  1,  IX.  1,  2,  X.  1,  XI.  1.  The  next 
most  frequent  seat  is  in  the  inner  nuclear  layer.  Here  there 
is  no  tendency  to  striation ;  the  extravasations  are  round  or 
irregular  (as  in  PI.  YI.  4,  XII.  1).  If  the  extravasation  in 
this  position  is  large  it  may  separate  the  retina  from  the 
choroid,  while  a  haemorrhage  in  the  nerve-fibre  layer  may 
break  through  into  the  vitreous.  This  sometimes  happens- 
in  Bright's  disease,  as  in  one  case  which  came  under  my 
observation.1  The  patient,  a  girl  of  seventeen,  was  admitted 
under  Sir  Wm.  Jenner,  suffering  from  chronic  Bright's  disease 
and  hemiplegia.  On  admission  there  was  well-marked  albu- 
minuric  retinitis  of  the  usual  type.  A  fortnight  later,  a 
haemorrhage  occurred,  partly  obscuring  the  fundus.  It  did 
not  become  diffused,  but  remained  attached  to  the  retina  by 
a  pedicle. 

Now  and  then,  especially  in  the  neighbourhood  of  the 
macula  lutea,  the  blood  may  be  extravasated  in  a  thin  film 
between  the  retina  and  the  vitreous.  Such  an  extravasation 
is  commonly  very  irregular  in  shape,  the  irregularity  being 
sometimes  increased  by  the  extension  of  processes  of  blood 
into  the  vitreous.  Occasionally  a  large  hemispherical 
haemorrhage  is  found  at  the  macula,  bounded  superiorly 
by  a  straight  horizontal  line.  Here  the  blood  seems  to 
See  also  "  Ophth.  Review,"  vol.  vii.  p.  132. 


CHANGES    IN    THE    RETINAL    VESSELS HEMORRHAGE.       27 

be  effused  between  the  internal  limiting  membrane  of  the 
retina  and  the  hyaloid  membrane,  which  are  more  loosely 
attached  to  each  other  in  this  situation  than  elsewhere. 
The  blood  quickly  gravitates  to  the  lower  part  of  this  space, 
where  it  is  confined  by  the  comparatively  close  connection 
between  the  above-mentioned  membranes  there  existing, 
and  we  thus  get  a  haemorrhage  of  the  characteristic 
hemispherical  form.  The  more  recent  the  haemorrhage  the 
brighter  is  its  colour.  Old  haemorrhages  may  be  almost 
black.  Haemorrhages  may  cause  permanent  white  spots. 
There  may  be  a  haemorrhage  one  day,  and  the  next  a  white 
spot  in  its  centre.  As  the  blood  goes  (which  it  does  quickly), 
a  white  patch  may  remain,  never  so  large  as  the  haemorrhage. 

It  is  doubtful  whether  extravasations  into  the  retina 
occur,  however  small,  except  from  actual  rupture  of 
vessels;1  probably  the  extravasations  are  conditioned  by 
degeneration  of  minute  vessels,  sometimes  by  such  capil- 
lary aneurisms  as  are  shown  in  Fig.  3.  White  spots  or 
brilliant  plates  of  cholesterin  are  often  seen  in  the  retina 
adjacent  to,  or  left  by,  extravasations  (PL  XI.  1).  These 
spots,  when  small,  may  be  granular ;  when  large,  they  may 
be  filmy.  They  are  probably  due  to  fatty  degeneration  of 
the  disturbed  retinal  elements  or  of  the  effused  blood. 

Small  extravasations  are  readily  absorbed;  larger  ones 
more  slowly.  Sometimes  pigmentary  degeneration  results, 
and  an  irregular  black  spot  is  left.  The  white  spots  disappear 
very  slowly,  and  white  granules  may  remain  for  a  long  time. 

Symptoms. — Small  haemorrhages,  away  from  the  centre  of 
the  retina,  may  give  rise  to  no  symptoms.  Larger  ones  cause 
loss  of  vision  at  the  spot  from  the  local  damage  to  the  retina, 
the  loss  being  serious  in  proportion  to  the  proximity  to  the 
macula  lutea,  in  which  a  small  extravasation  may  cause 
permanent  loss  of  central  vision.  A  ring  of  haemor- 
rhage around  the  macula  may  cause  considerable  central 
amblyopia  (PI.  XL  2).  Occasionally  the  patient  is  con- 
scious of  the  red  colour  of  the  extra vasated  blood  (see 

1  According  to  Leber  they  are  frequently  due  to  diapedesis.  "Graefe  u. 
Saemisch's  Handbuch,"  vol.  v.  p.  557. 


28  MEDICAL   OPHTHALMOSCOPY. 

under  "Leucocythsemia").  At  the  moment  of  extravasation 
there  may  be  no  symptoms,  or  there  may  be  sudden  dimness 
of  sight,  or  there  may  be  ocular  spectra. 

Causes. — Haemorrhage  into  the  retina,  as  elsewhere,  depends 
on  one  or  both  of  two  causes — increased  intra- vascular  pressure, 
decreased  strength  of  vascular  wall.  Local  increased  blood 
pressure  is  a  common  cause.  In  optic  neuritis  with  much 
constriction  of  the  veins,  the  whole  fundus  may  be  covered 
with  extravasations  (PI.  VI.  1).  Similar  extravasations 
may  attend  all  forms  of  retinitis.  They  may  be  large  and 
abundant  in  thrombosis  of  the  retinal  vein,  as  Michel  has 
shown  (see  p.  31).  General  increased  blood-pressure  is  an  occa- 
sional cause.  High  arterial  tension  may  often  be  traced  in 
cases  of  retinal  haemorrhage  in  which  no  other  cause  can  be 
discovered.  But  it  is,  on  the  whole,  a  rare  accident,  consider- 
ing the  frequency  with  which  high  tension  exists.  Its  rarity 
may  be  due  to  the  efficient  support  of  the  retinal  vessels,  as 
explained  in  the  description  of  the  effects  of  passive  conges- 
tion. It  is  sometimes  seen  when  hypertrophy  of  the  left 
ventricle  can  tell  unduly  on  the  vascular  system.  In  the 
peculiar  vascular  condition  which  attends  arrested  menstrua- 
tion, haemorrhages  occasionally  occur :  more  rarely  in  sup- 
pression of  some  other  habitual  discharge.  Mr.  Spencer 
Watson1  has  recorded  an  instance  of  extensive  retinal  extra- 
vasation in  a  woman  at  the  climacteric  period,  in  whom  there 
was  high  arterial  tension,  which  was  ultimately  relieved  by  a 
copious  epistaxis.  Another  cause  is  sudden  loss  of  blood 
(see  "  Acute  Anaemia  "). 

In  some  cases  of  heart  disease,  especially  when  conjoined 
with  degenerated  vessels,  numerous  extravasations  occur  into 
the  retina,  with  signs  of  parenchymatous  retinitis,  venous 
distension,  and  diffuse  cloudiness.  This  condition  has  been 
called  "  haemorrhagic  retinitis."  It  may  occur  without  any 
recognizable  cardiac  disease  in  apparently  healthy  persons 
after  middle  life,  and  is  often  unilateral.  It  probably  is  the 
result,  in  some>  cases,  of  thrombosis  in  the  retinal  vein.  Mr. 
Hutchinson  has  adduced  strong  evidence  to  show  that  it  is 

1  "  Trans.  Ophth.  Society,"  vol.  i.  p.  41. 


CHANGES    IN    THE    RETINAL    VESSELS HAEMORRHAGE.      29 

occasionally  due  to  a  gouty  diathesis,  acquired  or  inherited 
(see  Part  II.,  "Grout"). 

Degeneration  of  the  retinal  vessels  is  a  frequent  .cause  of 
haemorrhage,  although  it  is  not  often  that  it  can  be  demon- 
strated post-mortem.  It  is  doubtless  owing  to  this  degenera- 
tion that  retinal  extravasations  are  so  common  in  certain 
general  blood  diseases,  especially  in  kidney  diseases  and 
diabetes,  pernicious  anaemia,  leucocythsemia,  ague,  purpura, 
scurvy  and  pyaemia,  and  many  exhausting  conditions,  such 
as  over-lactation.  In  some  of  these  cases,  as  pyaemia  and 
leucocythsemia,  the  blockade  of  vessels  may  assist.  Capillary 
aneurisms  from  a  case  of  retinal  haemorrhage  in  diabetes  and 
diseased  capillaries  in  renal  retinitis  are  shown  in  Fig.  3. 
Jaundice  is  also  an  occasional  cause  of  retinal  haemorrhage. 

Apart  from  these  blood  diseases,  retinal  haemorrhage  may 
occur  from  simple  senile  vascular  degeneration.  In  such 
cases  it  is  sometimes  produced  by  violent  effort,  such  as 
that  of  a  cough,  or  in  straining  during  defaocation.  In  all 
conditions  of  vascular  degeneration  its  occurrence  is  of  im- 
portance, on  account  of  its  occasional  association  with  cerebral 
haemorrhage.  This  is  well  exemplified  in  the  case  of  leuco- 
cythsemia (q.  v.}. 

Sometimes  retinal  haemorrhage  results  from  blows  upon 
the  eye  or  skull.  Rarely  haemorrhages  are  observed  in 
young  persons  without  discoverable  cause.  A  remarkable 
series  of  cases  in  young  men  has  been  recorded  by  Eales,  of 
Birmingham.1  The  only  etiological  condition  with  which  it 
could  be  associated  was  habitual  constipation.  The  cases 
will  be  again  alluded  to  in  the  section  on  "  Affections  of  the 
Digestive  System." 

The  prognosis  depends  on  the  position  of  the  haemorrhage, 
and  011  the  extent  to  which  its  causes  are  under  control.  It 
is  worse  when  there  are  signs  of  general  retinitis. 

The  chief  local  treatment  is  the  application  of  cold  and 
gentle  pressure  on  the  eyeball,  to  give  temporary  support  to 
the  vessels,  and  obtain  contraction.    Other  measures  are  those 
suited  for  the  general  state,  and  for  haemorrhage  elsewhere. 
1  "  Birm.  Med.  Review,"  July,  1880,  j».  262. 


30  MEDICAL   OPHTHALMOSCOPY. 

Haemorrhage  from  the  choroidal  vessels  is  rare,  and  pos- 
sesses little  medical  significance. 

THROMBOSIS. —  Veins. — Thrombosis  is  occasionally  observed 
in  smaller  branches  of  the  veins,  which  then  lose  their  double 
contour — i.e.,  their  central  reflection  disappears,  and  they 
appear  dark  and  large,  their  branches  being  unduly  con- 
spicuous. The  condition  usually  depends  on  local  causes,  and 
has  little  general  significance.1 

Thrombosis  may  also  occur  in  the  central  vein  of  the  retina 
behind  tjie  eye.  It  is  met  with  chiefly  in  the  old,  in  whom 
thrombosis  elsewhere  is  common,  and  has  been  seen  in  associa- 
tion with  senile  gangrene  of  the  foot  (Angelucci).  But  it 
occasionally  occurs  also  in  younger  persons,  in  association 
with  heart  disease,  aortic  and  mitral.  Of  four  cases  recorded 
by  Angelucci,2  three  were  in  young  persons,  aged  twenty- 
one,  twenty-three,  and  twenty-four.  In  these  it  is  ap- 
parently due  to  phlebitis.  In  one  case3  the  vein  at  the  spot 
thrombosed  was  thickened  to  three  times  the  normal  size, 
chiefly  from  changes  in  the  external  coat.  The  new  tissue 
consisted  of  concretions  such  as  are  met  with  in  psammo- 
mata,  and  was  ascribed  to  an  inflammatory  process  in  the 
connective  tissue  of  the  central  canal  of  the  nerve.  The 
thickening  of  the  vein  was  so  great  that  it  must  have 
compressed  the  artery.  It  is  somewhat  remarkable  that  the 
accident  does  not  more  frequently  follow  a  primary  neuritis. 
Only  one  case  has  been  recorded  in  which  thrombosis  was 
supposed  to  have  resulted  from  a  primary  inflammation.4 

The  symptoms  observed  have  presented  considerable  varia- 

1  Under  the  title  "Primary  Retinal  Phlebitis,"  Mules  has  lately  recorded 
two  cases  where  the  thrombosis  was  confined  to  branches  of  the  central  vein. 
There  was  no  local  disease  found  to  account  for  the  condition,  but  evidence  of 
choroiditis  subsequently  appeared  in  one  of  the  cases.  The  general  bearing 
of  the  thrombosis  is  not  apparent,  though  Mules  considers  that,  in  one  of  the 
patients,  the  phlebitis  was  due  to  gout.  In  neither  was  there  any  optic 
neuritis.  See  "Trans.  Ophth.  Soc.,"  vol.  ix.  1889,  p.  130. 
"  *  "Ann.  d'Ocul.,"  18SO,  ii. 

3  Angelucci:  "  Kl.  Monatsbl.,"  August,  1878;  Zehender  :  "  Bericht  iiber 
11  Versam.  Ophth.  Ges  1.,"  p.  182. 

4  Fox  and  Brailey  :  "  Ophth.  Hosp.  Rep.,"  vol.  x.  pt.  ii.,  June,  1881,  p.  205. 


CHANGES    IN    THE    RETINAL    VESSELS THROMBOSIS.          31 

lion.  There  is  always  sadden  failure  of  sight,  often  dis- 
covered on  waking  in  the  morning.  It  is  usually  incomplete, 
and  soon  presents  slight  improvement.  In  the  most  severe 
•cases  observed  by  Michel,1  the  ophthalmoscopic  appearances 
were  those  of  an  intense  haemorrhagic  retiuitis.  The  veins 
were  extremely  distended  and  tortuous;  the  retina  around 
the  papilla  was  suffused  with  blood,  beyond  this  zone  of 
extravasation  were  circumscribed  haemorrhages,  and  around 
the  macula  lutea  there  was  a  greyish  discoloration.  The 
vitreous  sometimes  became  opaque.  In  other  cases,  in  which 
it  was  assumed  that  the  occlusion  of  the  vein  was  incom- 
plete, there  were  merely  broad  striated  haemorrhages  around 
the  papilla,  and  round  and  oval  haemorrhages  towards  the 
periphery,  the  arteries  being  indistinct,  and  the  veins  dark 
and  tortuous.  In  still  slighter  cases,  supposed  to  be  of  the 
same  nature,  there  were  no  haemorrhages,  but  merely  a 
disproportion  between  the  arteries  and  the  veins.  In  most 
instances  the  disc  was  little  affected. 

That  haemorrhages  may  be  absent  even  when  the  occlu- 
sion of  the  vein  is  complete,  is  proved  by  the  case  recorded 
by  Augelucci,2  in  which  thrombosis  of  the  retinal  vein,  1  mm. 
behind  the  lamina  cribrosa,  was  associated  with  senile 
gangrene  of  the  foot.  The  veins  were  tortuous,  but  there 
were  no  haemorrhages. 

In  the  case  recorded  by  Fox  and  Brailey  glaucoma  super- 
vened, but  the  evert  is  exceptional ;  in  most  recorded  cases 
the  tension  of  the  eye  was  normal. 

In  thrombosis  of  the  retinal  vein  the  loss  of  sight  is  less 
complete  than  in  embolism  of  the  artery,  and  the  ophthal- 
moscopic appearances  differ  in  that  the  arteries,  as  a  rule, 
although  they  may  be  slightly  narrowed,  are  not  empty,  or 
filiform, — in  the  enormous  distension  of  the  veins, — and  in  the 
circumstance  that  venous  pulsation  can  usually  be  observed, 
and  that  the  veins  may  appear  interrupted  here  and  there. 
But  in  some  cases  the  appearances  simulate  those  of  embolism 
very  closely.  There  may  be  a  cherry-red  spot  at  the  macula, 

1  "  Archiv  f.  Ophtli.,"  vol.  xxiv.  pt.  2,  p.  37. 

2  "  Klin.  Monatsbl.,"  October,  1878.     See  also  the  same,  January,  1880. 


32  MEDICAL   OPHTHALMOSCOPY. 

and  in  severe  cases  (probably  in  which  the  central  artery  is 
compressed  by  the  distension  of  the  vein  from  clot,  or  by  the 
thickening  of  the  wall  which  caused  the  thrombosis)  the 
arteries  may  be  extremely  narrow,  the  veins  partly  emptied 
of  blood,  and  the  disc  pale.  These  were  the  appearances  in 
a  case  recorded  by  Angelucci,1  in  which  the  thrombosis  was 
demonstrated  post-mortem. 

Artery. — Thrombosis  has  been  observed  in  the  retinal 
artery  with  ocular  signs  identical  with  those  of  embolism,  to- 
be  described  immediately.  In  a  case  recorded  by  Sichel  it 
was  conjoined  with  foci  of  softening  and  small  haemorrhages 
in  the  brain.  Thrombosis  in  the  ophthalmic  artery  occurs 
as  a  very  rare  event,  and  probably  always  as  the  result  of 
thrombosis  in  the  internal  carotid.  I  am  not  aware  that  any 
case  has  been  observed  during  life,  but  some  years  ago  I  made- 
a  necropsy  on  a  case  in  which  this  accident  had  occurred. 
The  patient,  an  aged  man,  had  suffered  from  cerebral  soften- 
ing in  the  region  supplied  by  the  left  middle  cerebral  artery, 
which  was  much  diseased.  A  fortnight  or  three  weeks  before 
his  death,  there  was  no  ocular  or  ophthalmoscopic  change. 
He  lay  in  a  comatose  condition,  and  his  eyes  were  not  again 
examined.  Post-mortem,  a  recent  clot  was  found  extending 
down  into  the  intra-cranial  portion  of  the  left  internal  carotid, 
fully  distending  it,  and  passing  also  into  the  commencement  of 
the  ophthalmic  artery,  which,  however,  near  the  eyeball,  was 
pervious,  being  only  partially  obstructed  by  clot.  The  eyeball 
was  quite  rotten,  the  sclerotic  of  a  brownish  colour,  and  giving 
way  before  the  scissors  like  brown  paper.  The  retina  was 
greatly  atrophied,  reduced  to  two- thirds  of  its  normal  thick- 
ness. Its  several  layers  were  no  longer  recognizable.  The 
outer  half  was  occupied  by  a  thick  layer  of  nuclei,  apparently 
representing  the  two  nuclear  layers.  Its  inner  half  consisted 
of  a  series  of  lacunse,  limited  by  the  remains  of  the  thick- 
ened vertical  fibres.  No  nerve-fibre  layer,  ganglion  cells,  or 
molecular  layers  could  be  discovered.  A  case  of  the  same 
character,  but  in  which  a  freer  collateral  circulation  was. 
established  and  the  retinal  changes  were  slighter,  has  been 

1  Loc.  cit  1878. 


CHANGES    IN    THE    RETINAL    VESSELS EMBOLISM.  66 

recorded  by  Yircliow,  and  is  described  further  on  in  the 
section  on  "Softening  of  the  Brain."  Parinaud1  relates  a  case 
of  thrombosis  of  the  central  artery  of  the  retina,  followed  by 
symptoms  of  cerebral  softening,  in  a  woman  aged  seventy- 
one,  who  was  suddenly  seized  with  dimness  of  vision  in  the 
left  eye,  accompanied  by  the  appearance  of  green  and  yellow 
spots  on  a  grey  ground.  A  few  days  later  there  was  a 
central  scotoma  with  pronounced  peripheral  limitation  of  the 
field  of  vision,  and  loss  of  colour-sense.  Ophthalmoscopically 
the  only  change  observed  was  a  diminution  in  the  calibre  of 
both  veins  and  arteries,  followed  ten  days  later  by  oedema 
of  the  retina  with  haemorrhages,  and  capillary  congestion 
around  the  macula.  Three  months  later  there  was  atrophy 
of  the  disc,  and  several  branches  of  the  central  artery  were 
filiform  and  white.  Subsequently  she  developed  loss  of 
memory,  aphasia,  and  hallucinations. 

Priestley  Smith2  has  urged  that  arterial  thrombosis  is  the 
lesion  in  many  cases  that  are  thought  to  be  embolism.  He 
regards,  as  its  causes,  heart-failure  (either  from  organic 
disease  or  other  cause),  spasm  of  the  vessels  or  disease  of 
their  walls,  and  blood-states.  The  transient  failure  of  sight 
in  the  opposite  eye  at  the  onset  he  ascribes  to  spasm  of  the 
retinal  vessels. 

EMBOLISM. — The  central  artery  of  the  retina  is  not  unfre- 
quently  occluded  by  an  embolus,  and  the  occurrence  is  of 
much  medical  interest.  Nowhere  else  can  the  phenomena  of 
vascular  occlusion  be  observed  during  life.  The  accident  is 
commonly  the  consequence  of  heart  disease,  and  is  sometimes 
the  first  thing  which  draws  attention  to  the  existence  of  the 
cardiac  affection.  It  was  so  in  the  case  of  a  girl  who  came 
under  my  observation  suffering  from  sudden  loss  of  sight 
in  one  eye.  On  examination  she  was  found  to  have  a  loud, 
distinct  presystolic  murmur.  There  was  no  previous  history 
of  rheumatic  fever  or  scarlatina,  and  there  were  absolutely 
no  symptoms  pointing  to  cardiac  disease  beyond  the  affection 
of  sight.  Embolic  infarction  in  other  organs  in  many  cases 

1  "  Gaz.  Med.  de  Paris,"  1882,  p.  627.         2  "  Oplith.  Rev.,"  vol.  iii 

I) 


34  MEDICAL    OPHTHALMOSCOPY. 

coexists,  and  the  ocular  accident  may  indicate  the  nature  of 
disturbance  elsewhere.     It  occasionally  coexists  with  cerebral 
embolism,  and  may  even  furnish  a  warning  of  the  proba- 
bility of  the  latter,  as  in  a  case  recorded  by  Landesberg,  in 
which  the  ocular  embolism  was  followed,  a  week  later,  by 
loss  of  consciousness  and  hemiplegia.     This  patient  suffered 
at  different  periods  from  embolism  of  eacli  retinal  and  one 
cerebral  artery.     The  cerebral  and  ocular  accidents  may  occur 
simultaneously.      The    diagnosis   of   cerebral    embolism   is 
usually  sufficiently  clear  without  it,  but  its  occurrence  is  an 
important   corroborative,   and   almost   demonstrative,   proof 
of  the  nature  of  the  cerebral  lesion.     Retinal,  as  cerebral, 
embolism  is  rather  more  frequent  on   the  left  than  on  the 
right  side.     Its  common  cause  is,  as  already  stated,  cardiac 
disease,  especially  mitral  stenosis.     It  has  also  been  observed 
in  atheroma  of  the  aorta  and  in  febrile  diseases,  pregnancy, 
and  Bright 's  disease,  probably  from  the  formation  of  a  clot 
and  its  detachment.     It  may,  therefore,  occur  at  any  age. 
A   case   at   seventy-four  years   of   age   has   been    recently 
recorded  lay  Hirschberg.1 

The  position  of  the  obstruction  may  be  in  the  trunk,  or  in 
one  of  the  branches.  In  each  case  there  is  sudden  and  com- 
plete loss  of  sight,  persistent  when  the  obstruction  is  in  the 
trunk  and  is  permanent.2  In  rare  cases  the  loss  of  sight  is  not 
instantaneous,  but  comes  on  in  the  course  of  a  few  minutes, 
commencing  at  the  periphery.  When  the  obstruction  is  in  a 
branch,  the  loss  of  sight  usually  rapidly  clears,  except  from 
that  portion  of  the  retina  which  is  supplied  by  the  occluded 
vessel. 

The  arteries  beyond  the  obstruction  are  deprived  of  their 
supply  of  blood,  and  contract,  so  that  to  the  ophthalmoscope 
they  appear  as  fine  lines  only  (PI.  XII.  2).  They  commonly, 

1  "Arch,  f.  Augenheilkunde,"  vol.  v.,  April,  1879,  p.  166. 

2  Should  the  retina  be  nourished  in  part  by  a  cilio-retinal  artery,  embolism 
of  the  trunk  of  the  central  vessel  will  not  cause  complete  loss  of  sight,  since 
the  retinal  area  corresponding  to  the  distribution  of  the  abnormal  artery  will 
retain  its  function.     Such  a  case  is  recorded  by  Benson  ("  Ophth.   Hosp. 
Rep.,"  vol.  x.,  pt.  iii.,  1882,  p.  336). 


CHANGES    IN    THE    RETINAL    VESSELS EMBOLISM.  35 

however,  retain  their  red  colour,  because  the  contraction  does 
not  obliterate  their  cavity,  although  reducing  it  almost  to 
capillary  dimensions,  and  there  is  still  a  narrow  column 
of  blood  within  them.  Towards  the  periphery,  however, 
they  are  so  small  as  to  be  invisible.  The  delicate  wall  of 
the  vessel  is  unrecognizable,  except  in  the  larger  vessels, 
where,  on  account  of  its  contracted  state,  it  is  more  distinct 
than  normal,  and  appears  as  a  white  line  on  each  side,  bound- 
ing the  narrow,  red  column.  When  the  obstruction  is  com- 
plete and  no  collateral  circulation  is  established,  the  red 
column  may  disappear,  and  only  a  white  line  indicate  the 
position  of  the  empty  vessel,  which  gradually  becomes  trans- 
formed into  fibrous  tissue  (PL  XII.  3).  In  this  drawing  the 
arterial  branch  which  passes  upwards  and  to  the  left  is 
represented  only  by  a  branching  white  line,  while  one  which 
passes  vertically  upwards,  and  is  not  quite  empty,  is  bounded 
on  each  side  by  a  white  line.  Sometimes  detached  columns 
or  cylinders  of  blood  are  seen  in  the  arteries  and  in  the  veins, 
moving  onwards  in  pulsatile  jerks.  This  is  probably  seen 
only  when  the  obstruction  is  incomplete. 

The  veins  are  narrowed,  but  less  than  the  arteries.  They 
are  sometimes,  but  not  always,  broader  towards  the  periphery 
than  near  the  disc. 

The  optic  disc  is  paler  than  normal,  and  the  pallor  gra- 
dually increases.  The  retina  undergoes  very  marked  changes, 
consequent  on  the  disturbance  of  its  nutrition.  It  presents 
a  greyish  or  white  opacity,  always  most  marked  around  the 
macula  lutea  (PI.  XII.  2),  and  commonly  also  conspicuous 
around  the  disc.  This  opacity  may  come  on  in  a  few  hours, 
but  sometimes  not  for  some  days.  The  opacity  usually  stops 
short  of  the  fovea  centralis,  leaving  it  of  a  bright  red  colour, 
so  red  that  it  was  thought  to  be  extravasation,  but  it  is  now 
generally  believed  that  the  tint  is  merely  the  effect  of  contrast 
with  the  adjacent  pale  opacity.  The  latter  is  believed  to 
depend  on  oedema  of  the  nerve-fibre  layer,  and  the  thinness  or 
absence  of  that  layer  at  the  fovea  centralis  to  be  the  cause  of 
the  usual  freedom  of  that  part  from  opacity  (Liebreich).  But 
occasionally  the  fovea  may  be  as  opaque  as  its  vicinity,  as  in 


36 


MEDICAL    OPHTHALMOSCOPY. 


PI.  XII.  2.  Here  I  found  the  opacity  to  depend  011  much 
graver  structural  alterations  than  are  usually  supposed  to 
exist.  Besides  evidences  of  oedema,  there  was  an  infiltration 
of  all  the  retinal  layers  with  lymphoid  cells,  similar  to  those 
of  the  nuclear  layers,  so  that  the  thickened  vertical  fibres 
were  the  only  structural  elements  which  could  he  dis- 
tinguished. The  layer  of  rods  and  cones  was  destroyed, 
probably  during  life,  in  the  region  of  the  macula,  because  the 
pigment-epithelium  was  in  contact  with,  and  adherent  to,  the 
outer  nuclear  layer.  In  other  places  the  thickened  vertical 
fibres  were  widely  separated. 

Haemorrhages  are  sometimes  met  with.     The  opacity  com- 
monly disappears  in  the  course  of  a  few  weeks,  but  may  leave 


YIG.  4.— EMBOLISM  OF  THE  CENTRAL  ARTERY  OF  THE  RETINA  (PL.  XII. 

Longitudinal  section  through  the  artery,  one-eighth  of  an  inch  (3  mm.) 
behind  the  eyeball.  On  each  side  the  nerve-fibres  are  indicated,  and 
between  these  and  the  vessel  is  much  loose  connective  tissue.  Within 
the  contracted  vessel  is  an  oval  granular  mass,  and  in  front  of  this  is  a 
.small  round  body  (  x  300). 


CHANGES    IN    THE    RETINAL    VESSELS EMBOLISM.  3? 

white  spots,  due  to  foci  of  degeneration.  The  edges  of  the 
optic  disc  are  usually  hazy.  In  most  cases  the  pallor  per- 
sists and  increases,  and  passes  into  the  whiteness  of  atrophy, 
which,  at  last,  resembles  closely  simple  atrophy,  except  m 
the  extremely  small  size  of  the  vessels. 

The  plug  has  in  several  cases  been  found  after  death, 
commonly  just  behind  the  bifurcation  of  the  artery,  in  other 
cases  in  its  course.  In  a  case  of  embolism  of  the  middle 
cerebral,  and  retinal  artery,  probably  occurring  simultaneously 
(figured  in  PI.  XII.  2),  the  artery  in  the  nerve  contained  an 
oval  granular  embolus  (Fig.  4).  Other  smaller  fragments 
were  seen  in  the  narrowed  arteries,  upon  the  disc. 

Very  rarely  the  circulation  gets  re-established  by  the  normal 
course.  Columns  of  blood  appear  in  the  arteries,  in  part 
interrupted,  and  for  a  long  time  easily  broken  up  by  pressure. 
The  arteries  continue  below  normal  size.  Vision  may  be 
recovered,  especially  at  the  periphery,  rarely  at  the  centre. 
Commonly,  however,  obstruction  remains  complete 

The  retinal  artery  is  regarded  as  a  "terminal"  artery- 
i.e.,  one  that  has  no  anastomoses.  In  most  cases  verv  little 
collateral  circulation  is  set  up :  the  arteries  remain  narrowed 
to  lines  as  far  as  they  can  be  traced.  But  they  are  visible  in 
almost  all  cases  as  red,  not  as  white,  lines.  Hence  they  must 
contain  blood,  persistent  and  therefore  circulating,  which  has 
come  from  some  slight  collateral  anastomoses,  or  from  the 
obstruction  being  incomplete. 

Sometimes  the  arteries  again  become  pervious  although 
diminished  in  size.  It  is  probable  that  this  is  due,  in  some 
cases,  to  the  partial  restoration  of  the  channel  of  the  artery, 
and  in  other  cases  to  the  establishment  of  considerable 
collateral  circulation.  In  PL  XII.  2,  for  instance,  the 
arteries  are  filiform  only  upon  the  disc,  and  as  far  as  they 
remain  unbranched ;  beyond  this,  they  have  nearly  their 
normal  size.  A  similar  case  has  been  recorded  by  Knapp. 
This  points  strongly  to  the  establishment  of  a  collateral 
circulation,  probably  by  connection  with  the  long  ciliary 
arteries,  although,  in  the  researches  of  Leber,  such  connections 
could  not,  in  the  normal  condition,  be  demonstrated.  It  is 
commonly  supposed  that  the  chief  connection  between  the 


38  MEDICAL    OPHTHALMOSCOPY. 

retinal  and  ciliary  vessels  is  by  means  of  the  vessels  of  the 
optic  disc,  but  it  is  doubtful  whether  it  is  by  this  means 
that  a  collateral  circulation  takes  place.  The  arteries  are 
never  filled  in  the  neighbourhood  of  the  disc,  but  at  a 
distance  from  it.  A  collateral  circulation  in  the  disc  may 
maintain  the  blood-supply  needful  to  preserve  the  red  colour 
of  the  filiform  arteries,  but  certainly  does  not  maintain  the 
peripheral  circulation  in  most  of  the  cases  in  which  this 
is  re-established  in  a  considerable  degree.  Probably,  as 
Mauthner  has  suggested,  there  are,  in  different  cases,  very 
variable  anastomoses.  The  re-establishment  of  the  circulation 
a  few  hours  after  the  obstruction,  has  been  observed  by  Wood 
White  and  by  Eales.1  In  each  case  recovery  of  sight 
occurred.  It  is  probable  that  the  clot  either  became  broken 
up  or  so  moved  as  to  allow  the  blood  to  pass.  In  Wood 
White's  case  the  event  was  apparently  produced  by  pressure 
on  the  globe  by  the  finger.  The  fact  is  of  interest  in 
connection  with  the  occasional  transient  duration  of  the 
symptoms  of  cerebral  embolism. 

In  PL  XII.  3  the  vessel,  which  is  still  pervious,  though 
narrowed,  is  bordered  for  a  distance  by  the  fine  white  line 
indicating  the  wall  thickened  by  contraction.  The  blood 
column  within  it,  narrow  as  it  is,  still  presents  a  central  reflec- 
tion, and  towards  the  periphery  the  vessel  again  widens  out 
exactly  as  in  the  other  case,  shown  in  Fig.  2  of  the  same  plate. 
This  broadening  of  the  peripheral  portion  of  the  vessel  nearly 
to  its  normal  calibre  indicates  that  blood  enters  it  beyond  the 
narrowed  portion  by  some  junction  with  other  arteries.2 

1  "  Ophth.  Rev.,"  vol  i.,  pp.  43  and  139.  Mules  also  has  recently  recorded 
a  case  where  plugging  of  a  branch  of  a  retinal  artery  disappeared,  under  mas- 
sage of  the  globe,  about  an  hour  after  its  occurrence.  The  visual  field  was 
restored  forthwith,  with  the  exception  of  a  small  area  corresponding  to  the 
immediate  neighbourhood  of  the  embolus.  ("Trans.  Ophth.  Soc.,"  vol.  viii., 
1888,  p.  151). 

8  It  is  greatly  to  be  desired  that,  in  any  post-mortem  examination  of  a 
case  in  which  there  has  been  embolism  of  the  retinal  artery,  and  in  which 
such  collateral  circulation  is  established,  a  ligature  should  be  placed  around 
the  artery,  or  around  the  optic  nerve  in  front  of  the  entrance  of  the  artery, 
and  the  ophthalmic  artery  then  injected,  so  as  to  discover  the  channels  by 
which  the  circulation  is  established,  and  which  elude  observation  under 
normal  conditions. 


CHANGES    IN    THE    RETINAL    VESSELS EMBOLISM. 


39 


In  partial  embolism  the  segment  of  the  retina,  to  which  the 
occluded  branch  goes,  becomes  opaque,  and  is  sometimes  the 
seat  of  numerous  haemorrhages.  Both  opacity  and  extrava- 
sations ultimately  disappear.  The  corresponding  portion  of 
the  optic  disc  may  be  normal,  as  in  the  case  shown  in  the 
figure,  or  it  may  be  atrophied.  In  one  case  on  record  it  was 
hypersemic  (De  Weaker).  The  corresponding  vein  is  at  first 
distended,  afterwards  smaller  than  normal. 

Embolism  of  the  trunk  of  the  central  artery  commonly 
causes  complete  and  persistent  loss  of  sight.  When  the 
occlusion  is  of  a  single  branch,  there  may  be  a  complete 
initial  loss  of  sight,  due  probably  to  the  plug  causing  a 
temporary  obstruction  in  the  trunk  of  the  artery  before  it 
passed  on  to  the  branch  in  which  it  was  arrested.  Occa- 
sionally, in  such  cases,  the  blindness  has  remained  complete, 
although  the  ophthalmoscope  afterwards  demonstrated  that 
only  one  branch  of  the  artery  was  occluded.  The  general 
retinal  anaemia  may,  in  such  cases,  have  been  so  prolonged  that 
the  nerve  elements  suffered  a  shock,  damaging  their  nutrition 
beyond  the  power  of  recovery  on  the  succeeding  restoration  of 
the  circulation.  Commonly,  in  such  cases,  the  permanent  loss 


PIG.  5.— DTAGBAM  OF  RIGHT  FIELD  OF  VISION  IN  PARTIAL  EMBOLISM  OF 
THE  CENTRAL  ARTERY  OF  THE  RETINA. 

The  descending  branches  of  the  central  artery  were  normal,  but  those  pro- 
ceeding upwards  were  empty.  The  shaded  area  indicates  the  portion  of 
the  field  in  which  sight  was  lost.  The  asterisk  indicates  the  position  of 
the  fixing  point,  the  dot  that  of  the  blind  spot. 


40  MEDICAL   OPHTHALMOSCOPY. 

is  of  a  portion  of  the  field  corresponding  to  the  distribution 
of  the  branch  plugged.  When  this  is  one  of  two  primary- 
divisions  of  the  artery,  the  loss  may  amount  to  one-half  of 
the  field ;  when  of  a  smaller  branch,  to  a  quadrant,  or  the 
like.  There  was  a  loss  of  nearly  one-half  in  the  case  figured 
in  PI.  XII.  2,  in  which  one  branch  running  upwards  and 
outwards  is  completely  obliterated,  and  others  running  up- 
wards and  inwards  are  partially  obliterated.  The  loss  was 
that  shown  in  the  adjacent  diagram  of  the  field  of  vision 
(Fig.  5). 

Occasionally,  sudden  blindness  has  occurred,  and-the  retinal 
arteries  have  appeared  narrow,  recovering  their  normal  size 
after  a  short  time,  with  restoration  of  vision,  as  in  the  cases 
of  "Wood  White  and  Bales,  discussed  above. 

Arterial  ischaemia,  similar  to  that  which  results  from 
embolism,  has  been  ascribed  to  a  retro-ocular  haemorrhage 
around  the  artery  compressing  it.  The  ophthalmoscopic 
distinction  of  this  from  embolism  is  uncertain,  and  probably 
depends  rather  on  the  incompleteness  of  the  ultimate  obstruc- 
tion than  on  any  differences  in  the  early  retinal  appearances. 
It  is  said  to  occur  in  cases  in  which  there  is  a  general 
tendency  to  haemorrhage,  and  to  be  the  precursor  of  cerebral 
extravasation.  An  interesting  case,  probably  of  this  character, . 
is  related  by  Hutchinson.1  It  is  possible  that  some  of  the 
cases  supposed  to  be  of  this  character  have  been  really  cases 
of  thrombosis  in  the  central  vein  compressing  the  artery 
(see  p.  30). 

THE  OPTIC  NERVE. 

The  alterations  in  the  optic  nerve,  as  seen  at  its  entrance 
into  the  eye,  are  among  the  changes  in  the  fundus  oculi  of 
greatest  importance  to  the  physician.  It  may  be  well,  before 
describing  those  changes,  to  consider  some  points,  regarding 
its  structure  and  appearance,  a  knowledge  of  which  is  essential 
for  a  correct  understanding  of  the  pathological  changes. 

In  the  optic  disc  we  have  presented  to  view  the  termination 
of  a  nerve — a  structure  consisting  of  nerve  fibres,  a  little 
supporting  connective  tissue  (especially  abundant  around  the 
1  "Ophth.  Hosp.  Rep.,"  October,  1874,  p.  51. 


CHANGES    IK    THE    OPTIC    NERVE.  41 

central  vessels),  and  a  number  of  blood-vessels,  for  the  most 
part  capillaries,  which  confer  on  the  disc  its  tint.  The  nerve 
fibres  radiate  and  spread  out  in  the  retina,  but  not  equally  on 
all  sides,  being  few  on  the  temporal  side,  towards  the  macula 
lutea,  and  numerous  on  the  nasal  side  and  especially  above 
and  below.  The  minute  vessels  of  the  disc  are  derived  partly 
from  the  posterior  ciliary  (choroidal)  arteries,  and  partly  from 
the  central  retinal  artery,  twigs  from  both  of  which  commonly 
unite  in  forming  the  "  circle  of  Haller,"  a  series  of  vessels 
which  surround  the  optic  nerve  behind  the  disc.  The  con- 
nective tissue  between  the  bundles  of  nerve  fibres  is  small  in 
quantity,  but  contains  scattered  nuclei.  The  opening  in  the 
sclerotic  is  funnel-shaped,  the  wider  part  being  posterior. 
The  termination  of  the  nerve  fits  pretty  closely  into  the 
inner,  smaller,  part  of  the  opening,  while  the  space  between 
the  nerve  and  its  outer  sheath,  "  vaginal  space,"  passes  up 
into  the  posterior  part  of  the  opening  (Fig.  16). 

The  separation  of  the  optic  nerve  fibres  to  radiate  into  the 
retina  leaves  the  central  hollow  known  as  the  "  physiological 
cup,"  the  size  and  depth  of  which  are  determined  by  the 
arrangement  of  the  nerve  fibres.  The  vessels  are  chiefly 
developed  among  the  nerve  fibres  and  towards  the  surface  of 
the  disc,  and  hence  the  central  cup  is  always  much  paler  than 
the  periphery.  It  is  commonly  white,  but  sometimes  mottled 
grey  from  the  reflection  of  the  white  trabeculse  of  the 
"  lamina  cribrosa,"  which  closes  in  the  sclerotic  foramen, 
and  through  the  meshes  of  which  the  greyer,  now  non- 
medullated,  nerve  fibres  pass.  The  tint  of  the  circum- 
ferential portion  of  the  disc  is,  as  already  explained,  deepest 
where  the  nerve  fibres  are  most  numerous,  and  hence  the 
nasal  half  of  the  disc  is  naturally  redder  than  the  temporal 
half.  The  arrangement  of  the  nerve  fibres  also  causes  the 
side  of  the  central  cup  to  be  steep  on  the  nasal  and  shallow 
on  the  temporal  side,  the  difference  being  proportioned  to 
the  inequality  with  which  the  nerve  fibres  are  distributed. 
When  the  fibres  are  almost  all  packed  on  the  nasal  side, 
the  cup  may  be  very  large,  and  extend  on  the  temporal 
side  to  the  margin  of  the  disc.  Often,  however,  there  is 
no  paler  central  cup. 


42  MEDICAL   OPHTHALMOSCOPY. 

The  boundary  of  the  "  disc,"  as  commonly  recognized,  is 
the  choroidal  ring,  i.e.,  the  edge  of  the  opening  in  the 
choroid  corresponding  to  that  in  the  sclerotic.  The  latter  is 
usually  the  smaller  of  the  two,  and  hence  a  narrow  rim  of 
sclerotic  commonly  appears  within  the  choroidal  edge,  and  is 
known  as  the  "sclerotic  ring."  It  is  often  visible  only  on 
one  side.  At  the  passage  of  the  nerve  fibres  over  the  edge 
of  the  sclerotic,  they  curve  a  little  above  the  level  of  the 
retina,  and  this  slight  prominence  has  suggested  the  name  of 
"  optic  papilla"  as  a  designation  for  the  area  of  entrance  of 
the  optic  nerve. 

The  trunk  of  the  optic  nerve  possesses  a  double  sheath  : 
the  inner  is  delicate,  closely  invests  the  nerve,  and  is  con- 
tinuous with  the  pia  mater  of  the  brain.  The  outer  sheath  is 
thicker  and  fibrous,  blends  in  front  with  the  sclerotic,  and  is 
continuous  at  the  optic  foramen  with  the  dura  mater.  There 
is  not,  as  was  once  thought,  a  reflection  of  the  arachnoid  at 
the  optic  foramen,  and  thus  the  vaginal  space  of  the  optic 
nerve — i.e.,  that  within  the  outer  sheath — is  continuous  with 
the  subarachnoid  and  subdural  spaces  around  the  brain. 
This  vaginal  space  is  traversed  by  tracts  of  tissue  connecting 
the  two  sheaths.  At  the  anterior  extremity  of  the  nerve, 
the  space  passes  within  the  posterior  part  of  the  sclerotic 
opening,  and  is,  according  to  some  authorities,  closed ;  but, 
according  to  others,  it  is  continuous  with  lymphatic  spaces 
in  the  substance  of  the  optic  nerve,  and  probably  also  in 
the  retina. 

The  optic  nerve,  at  its  entrance  into  the  eye,  undergoes 
certain  pathological  changes  in  common  with  the  retina. 
When  the  retina  is  generally  inflamed,  and  when  it  is 
atrophied,  the  optic  "papilla"  participates  in  the  change. 
But  it  also  undergoes  inflammatory  changes  independently 
of  the  retina. 

The  pathological  conditions  of  the  papilla  resolve  them- 
selves, from  their  clinical  features,  into  two  groups, — in- 
creased vascularity,  commonly  with  increased  prominence  ; 
diminished  vascularity,  commonly  with  shrinking.  The 
states  characterized  by  the  former  are  more  or  less  inflam- 
matory, and  are  often  included  under  the  generic  term 


CHANGES    IN    THE    OPTIC    NERVE CONGESTION.  43 

"  optic  neuritis."  Those  characterized  by  the  latter  signs 
are  accompanied  by  wasting  of  the  nerve  tissues,  and  are 
included  under  the  generic  term  "  optic  nerve  atrophy." 

It  must  be  remembered  that  the  term  "  optic  nerve "  is 
employed  in  two  senses — to  designate  the  whole  nerve,  and 
also  its  intra-ocular  termination  as  seen  with  the  ophthalmo- 
scope. To  prevent  the  confusion  arising  from  this  double 
use  of  the  words,  it  has  been  proposed  by  Leber  to  use  the 
terms  "  optic  nerve  "  and  "  optic  neuritis  "  when  speaking  of 
the  whole  nerve,  employing  only  the  words  "  papilla  "  and 
"  papillitis  "  to  designate  the  intra-ocular  termination  of  the 
nerve  and  its  inflammation.  This  distinction  has  not,  how- 
ever, come  into  general  use  in  this  country.  The  custom  of 
employing  the  term  "optic  neuritis"  as  a  designation  for 
the  intra-ocular  inflammation,  makes  it  inconvenient  to 
restrict  it  to  inflammation  of  the  nerve  trunk,  but  for  the 
former  condition  the  synonym  "  papillitis  "  is  very  useful. 

The  characters  of  these  morbid  states  may  be  thus  tabu- 
lated : — 

A. — Morbid  states  of  the  optic  nerve,  characterized  by  in- 
creased vascularity  or  signs  of  inflammation. 

1.  Simple   congestion   of  the   disc;  undue   vascularity, 

redness,  softening  but  no  obscuration  of  the  edge, 
and  no  swelling. 

2.  Congestion  with  oadema  of  the  disc  (slight  neuritis 

or  papillitis) ;  increased  redness,  with  slight  swell- 
ing; obscuration  of  the  edge  of  the  disc,  complete 
to  the  direct  examination,  incomplete  to  indirect 
examination. 

3.  Neuritis,  or  papillitis;  increased  redness  and  swell- 

ing, with  obscuration  of  the  edge  of  the  disc,  com- 
plete in  degree,  partial  or  total  in  extent. 
B. — Diminished  vascularity  and  signs  of  wasting. 

1.  Simple    atrophy;  increased    pallor  from  the    first; 

"  primary  atrophy." 

2.  Congestive  atrophy  ;  secondary  to  congestion  ;  pallor 

slowly  succeeding  simple  congestion. 


44  MEDICAL    OPHTHALMOSCOPY. 

3.  Neuritic   atrophy,   succeeding   pronounced   neuritis ; 

"  consecutive  atrophy,"  "  papillitic  atrophy." 

4.  Atrophy  succeeding  choroiditis  and  retinitis ;  "  cho- 

roiditic  "  and  "retinitic  atrophy." 

A..— MORBID  STATES  CHARACTERIZED  BY  INCREASED' 
VASCULARITY  OF  THE  DISC,  OFTEN  WITH  SIGNS  OF 
1NFLAMMA  TION. 

SIMPLE  CONGESTION. 

Increased  redness  is  the  universal  expression  of  tissue 
hypereBmia.  But  it  is  of  less  value  as  a  sign  of  hypersemia  of 
the  optic  disc  than  in  the  case  of  most  tissues,  on  account 
of  the  great  variation  in  the  amount  of  natural  redness. 
Attention  to  tint  of  disc  alone  is  a  prolific  source  of  error  in 
ophthalmoscopy.  It  is  as  if  a  small  portion  in  the  centre  of 
the  cheek  were  examined  to  determine  whether  or  not  there 
was  pathological  hypersemia.  Nevertheless,  ahnormal  redness 
of  the  disc  does  occur  as  a  morbid  state,  and,  although  in 
itself  a  sign  of  little  value,  it  derives  importance  from  certain 
concomitant  conditions.  It  is  significant  (a)  when  it  possesses 
special  characters  to  be  immediately  described ;  (6)  when 
developed  under  observation ;  and  (c)  when  it  is  notably 
greater  in  one  eye  than  in  the  other :  but  even  in  the  latter 
case  there  is  room  for  error  in  the  possibility  of  a  natural 
difference,  or  that  the  paler  eye  may  present  an  abnormal 
decrease  in  redness. 

There  are  certain  characters  which  aid  very  much  in  the 
recognition  of  the  pathological  increased  vascularity.  First, 
morbid  redness  has  usually  a  tendency  to  invade  the  physio- 
logical cup,  and  often,  especially  when  the  cup  is  small  and 
shallow,  to  obscure  it  altogether.  Secondly,  pathological 
redness  has  a  tendency  to  render  the  sclerotic  ring  or  the 
edge  of  the  choroid  indistinct ;  to  blur  the  sharpness  of  the 
outline  of  the  disc.  The  change,  when  very  slight,  may  be 
best  appreciated  by  examination  with  the  indirect  image 
(PL  I.  1).  It  is  due  to  the  circumstance  that  the  seat  of  the 
vascularity  is  the  layer  of  nerve  fibres,  and  it  may  extend  in 


CHANGES    IN    THE    OPTIC    NERVE CONGESTION.  45 

front  of  the  edge  of  the  disc ;  and  it  is  often  attended  with  a 
little  swelling  of  the  nerve  fibres  or  effusion  of  fluid,  which 
conceal  the  structures  beyond.  The  term  "  congestion  "is,  I 
think,  best  restricted  to  those  cases  in  which  the  increased 
vascularity  exists  alone,  with  so  little  structural  change,  that 
the  edge  of  the  disc  can  still  be  perceived  by  both  methods  of 
examination,  although  not  so  sharp  as  natural. 

The  redness  is  different  from  the  ordinary  tint  of  the 
•discs.  It  is  brighter,  softer,  somewhat  velvety  in  aspect, 
sometimes  finely  stippled.  Occasionally,  however,  the  tint 
of  a  disc  thus  changed  may  be  positively  paler  than  normal, 
although  the  uniformity  of  the  colour,  and  the  softened 
edge,  afford  evidence  of  the  pathological  character  of  the 
change  on  which  it  depends.  This  paler  tint  is  often  seen 
when  the  condition  is  passing  into  atrophy.  The  retinal 
vessels  are  usually  unchanged ;  their  walls  are  often  con- 
spicuous, by  contrast  with  the  redness  of  the  disc,  as  white 
lines  bounding  the  blood  column,  and  any  white  connective 
tissue  which  surrounds  them  at  the  point  of  emergence  is  also 
unduly  conspicuous  (PI.  I.  2).  The  appearance  is  suggestive 
of  the  white  tissue  being  a  pathological  result  of  the  hyper- 
semia. It  is  probable  that  it  is  so,  but  the  appearance  is 
too  common  as  a  physiological  condition  to  have  much 
value.  Its  distinctness  possesses  a  little  significance,  as  due 
to  the  invasion  of  the  middle  of  the  disc  by  the  hypersemia. 
Occasionally,  when  the  hypersemia  of  the  disc  is  the  expres- 
sion of  graver  changes  behind  the  eye,  the  arteries  may  be 
narrowed  in  consequence  of  retro-ocular  pressure. 

The  condition  thus  described  as  "  simple  congestion  "  of 
the  disc  is  usually  a  chronic  state,  and  corresponds,  pro- 
bably, to  the  condition  which  has  been  called  by  Clifford 
Allbutt  "chronic  neuritis."  The  evidence  that  there  is 
actual  inflammation  does  not  seem  sufficient  to  warrant  the 
application  to  this  state  of  the  term  "  neuritis,"  especially  as 
there  are  forms  of  true  neuritis  characterized  by  extreme 
chronicity.  It  is  rare,  I  think,  that  such  simple  hypersemia 
is  the  first  stage  of  an  actual  neuritis.  In  the  latter,  swelling 
comes  on  part  passu  with  the  hypersemia — i.e.,  congestion 


46  MEDICAL   OPHTHALMOSCOPY. 

with  oedema,  rather  than  simple  congestion,  is  the  first  stage 
of  neuritis.  The  simple  congestion  is  occasionally  seen  as 
a  substantive  condition,  and  ma}',  in  rare  cases,  precede 
atrophy.  The  condition  may  be  the  expression  of  a  state  of 
congestion  and  degeneration  in  the  whole  optic  nerve,  or  be 
apparently  limited  to  the  optic  disc.  It  is  not  unusual  in 
cases  of  hypermetropia.  It  may  occur  as  a  consequence  of 
injuries,  blows,  &c.,  in  the  neighbourhood  of  the  eye.  The 
affection  of  sight  which  results  from  the  use  of  tobacco  may 
be  attended  with  this  state.  It  occurs  also,  probably,  from 
other  toxic  agents,  as  lead.  It  has  been  observed  by  Clifford 
Allbutt  in  general  paralysis  of  the  insane;  and,  although 
some  other  observers  have  failed  to  find  it,  one  case  under 
my  observation  presented  it  very  distinctly.  It  has  also  been 
described  by  the  same  writer  as  accompanying  atrophy  in 
locomotor  ataxy ;  but  in  that  disease,  although  often  looked 
for,  it  has  not  been  found  by  others  or  by  myself.  It  is 
sometimes  present  in  cases  in  which  there  is  reason  to 
believe  a  similar  condition  exists  in  the  brain.  The  figures 
PL  I.  1  and  2  are  from  a  patient  with  cerebral  embolism, 
in  whom  the  condition  came  on  in  association  with  secondary 
brain  irritation — mental  failure  and  rapid  wasting  in  the 
paralyzed  limbs.  I  have  seen  a  similar  appearance  in  acute 
mania.  Microscopical  examinations  of  the  disc  in  this  state 
are  rare.  Clifford  Allbutt  examined  one  case  and  found  only 
distension  of  the  minute  vessels  with  that  granular  degenera- 
tion of  the  nerve  fibres  present  in  all  forms  of  atrophy. 

OPTIC  NEURITIS  OR  PAPILLITIS. 

CONGESTION  WITH  (EDEMA  (PI.  I.  3  and  4)  is  really  the 
first  stage  of  papillitis.  The  normal  rosy  tint  of  the  disc 
becomes  increased ;  its  edge  is  blurred,  but  is  recognizable 
on  indirect  examination.  There  is  a  pale  reflection  from 
the  adjacent  retina,  surrounding  the  disc  with  an  indistinct 
halo  (Plate  I.  3).  On  examining  the  disc  by  the  direct 
method,  the  morbid  appearance  is  much  more  marked 
(Plate  I.  4).  The  edge  of  the  disc  is  lost,  and  the  opacity  is 
seen  to  be  in  part  the  result  of  an  undue  distinctness  of  the 


CHANGES    IN    THE    OPTIC    NERVE NEURITIS.  47 

radiating  striation  of  the  nerve  fibres  as  they  course  on  to  the 
retina.  It  must  be  remembered  that  this  striation  is  often 
visible  as  a  normal  condition,  especially  above  and  below. 
Where  the  aggregation  of  the  fibres  is  very  close,  the  central 
cup  being  of  large  size,  the  appearance  of  commencing  oedema 
may  be  closely  simulated.  In  the  latter  condition,  however, 
there  is  from  the  first  more  or  less  invasion  of  the  central  cup, 
which  soon  becomes  obscured.  The  increased  vascularity  of 
the  disc  may  be  striated  at  the  periphery.  There  is  often 
distinct  swelling.  The  centre  of  the  papilla  may  be,  as  in 
the  figures  referred  to,  much  redder  than  the  periphery, 
on  account  of  the  slighter  central  swelling  allowing  the 
vascularity  of  the  disc  to  be  perceived.  .  In  the  periphery 
the  tint  of  the  choroid  is  concealed.  The  retinal  vessels  may 
be  normal,  or  the  veins  may  be  enlarged. 

It  is  important  to  note  that  the  direct  examination  renders 
these  changes  more  distinct.  If  the  obscuration  of  the  edge 
of  the  disc  is  apparent  only,  in  consequence  of  the  similarity 
in  tint  of  the  disc  and  the  adjacent  choroid,  the  edge  of  the 
disc  is  more  distinct  on  direct  than  on  indirect  examination. 
When  the  indistinctness  of  the  edge  is  due  to  the  opacity  of 
the  structures  in  front  of  it  (except  in  the  very  slightest 
form),  the  edge  is  less  distinct  on  direct  than  on  indirect 
examination.  This  is  no  doubt  due  mainly  to  the  fact 
that  the  illumination  is  stronger  and  the  plane  of  focus 
is  less  exact  in  the  indirect  method,  so  that  the  choroidal  edge 
and  the  tissue  in  front  of  it  are  in  view  at  the  same  time ; 
whereas  the  direct  method  of  examination,  by  its  higher 
magnification  and  more  exact  focussing,  shows  the  tissues  in 
front  of  the  edge  so  as  to  increase  the  concealment  of  the 
latter.  This  fact  will  often  be  found  of  service  in  distinguish- 
ing between  a  normal  redness  and  an  abnormal  obscuration 
of  the  disc.  Of  course,  it  will  not  distinguish  the  latter  from 
the  cases  just  mentioned,  in  which  there  is  a  slight  physio- 
logical obscuration  of  the  edge  by  nerve  fibres. 

This  condition  of  oedema  is  usually  an  acute  affection,  and 
is  commonly  the  first  stage  of  neuritis.  It  is  said  to  be  an 
effect  of  pressure  on  the  retinal  vein,  causing  passive  conges- 


48  MEDICAL    OPHTHALMOSCOPY. 

tion  of  the  retinal  vessels,  and  it  has  been  described  as  the 
result  of  the  general  passive  congestion  of  heart  disease.  In 
these  cases  it  may  be  associated  with  retinal  haemorrhages. 
It  may,  however,  occur  as  the  first  stage  of  neuritis  without 
the  least  sign  of  mechanical  congestion.  In  the  case  figured, 
there  was  probably  a  syphilitic  intra-cranial  node  or  growth. 

NEURITIS  (PAPiLLiTis).1 — From  congestion  with  oedema  to 
actual  inflammation  the  transition  is  one  of  degree.  It  seems 
better  to  restrict  the  term  neuritis,  or  papillitis,  to  those  cases 
in  which  the  swelling  and  opacity  are  sufficient  to  conceal  the 
edge  of  the  disc  both  on  direct  and  indirect  examination. 
This  condition  is  found  in  most  cases  to  result  not  merely 
from  vascular  congestion  and  oedema,  but  from  changes  in 
the  nerve  fibres  and  connective  tissue,  such  as  we  regard  as 
evidences  of  inflammation.  The  change  may  completely  veil 
the  whole  or  only  half  the  disc ;  and  from  such  a  slight  degree 
of  neuritis  to  the  most  intense  form  we  may  have  every 
gradation,  characterized  by  very  considerable  differences  in 
appearance. 

These  variations  in  the  appearance  of  the  disc  in  different 
cases,  and  supposed  differences  in  their  origin,  have  led  to 
the  establishment  of  two  varieties  of  the  affection,  "  descend- 
ing neuritis,"  and  the  "  choked  disc,"  "  Stauungs-papille." 
The  grounds  on  which  these  divisions  have  been  made  are, 
as  will  be  shown,  uncertain,  and  it  is  better  in  the  first  place 
to  consider  the  common  features  which  all  forms  of  papillitis 
possess.  The  supposed  varieties  and  theories  of  this  origin 
will  be  then  better  understood. 

A  case  of  optic  papillitis  of  considerable  intensity  presents, 
in  the  course  of  its  development,  certain  stages,  the  general 
features  of  which  are  usually  recognizable.  The  transition 
from  one  to  the  other  is,  of  course,  a  gradual  one,  and  cases 
are  seen  which  present  appearances  intermediate  between  the 
several  stages.  Moreover,  at  any  stage,  the  morbid  process 
may  stop,  remain  stationary  for  a  time,  and  then  recede. 
This  may  occur  spontaneously  or  as  the  result  of  treatment. 

1  Plates  I.  5,  6,  II.  1,  III.,  IV.,  V.,  VI.,  VII. 


CHANGES    IN    THE    OPTIC    NERVE NEURITIS.  49 

Thus  certain  forms  of  neuritis  maybe  distinguished  according 
to  the  intensity  of  the  changes,  but  our  knowledge  of  the 
conditions  on  which  they  depend  seems  insufficient  at  present 
to  distinguish  them  as  varieties  otherwise  than  as  varieties  of 
intensity,  on  whatever  differences  of  mechanism  they  may 
ultimately  be  proved  to  depend. 

The  first  stage  of  optic  neuritis  is  that  which  has  been 
already  described  as  "  congestion  with  oedema  " — a  condition 
of  increased  redness,  swelling,  and  cloudiness,  masking  the 
edge  of  the  disc  to  direct,  but  leaving  it  perceptible  to  indirect,* 
•examination.  In  this  condition  the  microscope  reveals  no  sign 
of  tissue  inflammation.  The  second  stage,  that  of  actual,  but 
slight,  neuritis,  is  characterized  by  the  disappearance  of  the 
edge  of  the  disc  even  to  indirect  examination  (PL  I.  5).  The 
transition  from  the  disc  to  the  retina  is  gradual,  the  edge  is 
"  blurred,"  and  its  position  has  to  be  guessed  at.  When  this 
is  the  case,  the  disc  always,  I  believe,  presents  not  only 
oedema  but  also  changes  in  its  tissue  elements  which  indicate 
a  process  of  inflammation — proliferation  of  nuclei,  escape 
of  leucocytes,  and  degeneration  of  nerve  structures — changes 
similar  to  those  which  are  regarded  in  all  organs  as  indicative 
of  inflammation. 

The  red  tint  of  the  disc  becomes  more  marked,  so  that  it 
may  be  almost  the  same  as  that  of  the  adjacent  choroid,  or  it 
assumes  a  reddish  grey  tint,  which  is  very  characteristic, 
and  the  disc  loses  its  normal  semi-translucent  appearance. 
The  swelling  increases,  and  is  easily  recognized,  even  on 
indirect  examination,  by  the  relative  displacement  of  different 
parts  on  lateral  or  vertical  movement  of  the  lens.  The 
striation  of  the  periphery,  perceptible  in  the  first  stage, 
increases,  but  becomes  redder.  It  is  due  not  only  to  the 
swelling  and  opacity  of  the  nerve  fibres,  but  also  to  the 
minute  vessels  which  course  between  them.  In  the  centre  of 
the  disc  the  redness  is  stippled  or  uniform,  not  striated,  and 
the  centre  is  commonly  distinctly  darker  red  than  the  peri- 
pheral portion  (PI.  I.  6).  The  centre  may  be  red,  and  the 
periphery  greyish  red.  The  striated  edge  passes,  by  grada- 
tion, into  the  tint  of  the  adjacent  fundus.  The  physiological 


50  MEDICAL    OPHTHALMOSCOPY. 

cup  often  disappears  during  the  stage  of  oedema ;  if  large,  a 
trace  of  it  may  remain  to  the  stage  of  commencing  neuritis, 
hut  is  rapidly  encroached  upon  and  covered  in  hy  the  swell- 
ing of  the  papilla  (see  PI.  III.  2,  in  which  it  has  almost 
disappeared) . 

White  lines  and  spots  are  not  uncommon,  especially  in  the 
cases  in  which  the  changes  remain  of  slight  degree.  They 
often  correspond  to  the  position  of  arteries  (PL  III.  3). 
The  swelling  and  obscuration  may  involve  all  parts  of  the 
'disc  equally,  especially  in  the  more  acute  forms  of  neuritis, 
or  it  may  be  much  more  marked  on  the  nasal  than  on  the 
temporal  side  of  the  disc.  The  difference  may  be  so  great 
that  the  position  of  the  edge  of  the  disc  may  be  distinct  on 
the  temporal  side,  while  the  nasal  edge  is  completely  obscured 
by  opaque  tissue — a  condition  which  may  for  brevity  be 
termed  "  hemi-neuritis "  (PI.  Y.  1,  2,  4).  Haemorrhages 
are  not  uncommon  in  this  stage,  sometimes  on  the  surface 
of  the  swelling,  or  even  on  the  least  changed  part  of  the 
disc  (PI.  V.  1)  or  just  beyond  its  edge  (PI.  V.  4).  They 
are  always  small.  The  arteries  usually  present  little 
change  in  the  slighter  stage  of  neuritis,  although  often 
recognized  with  difficulty  on  account  of  the  colour  of  their 
blood  corresponding  to  the  tint  of  the  disc.  They  are  a 
little  concealed  at  their  emergence,  but  have  a  nearly 
straight  course.  Arterial  pulsation  has  been  observed  by 
Graefe1  and  Becker.2  The  veins  lose  their  central  reflection 
as  they  pass  down  the  sides  of  the  swelling,  and  appear 
dark.  They  may  or  may  not  present  dilatation,  indicative 
of  mechanical  congestion.  In  the  early  stage  of  papillitis 
from  tumour,  as  a  rule,  they  less  frequently  present  dilata- 
tion than  in  that  from  meningitis. 

As  the  papillitis  goes  on,  the  swelling  increases,  and 
becomes  often  so  great,  that  there  may  be  a  difficulty  in 
seeing  the  surface  of  the  swelling  by  the  direct  method 
without  the  use  of  a  convex  lens.  The  veins,  as  they  curve 
down  the  sides  of  the  swelling,  appear  still  darker  and 

1   "Arch.  f.  Ophth.,"  xi.  pt.  1,  201,  and  xii.  pt.  2,  131. 
J  "Wien.  Med.  Wochenschrift,"  1873,  p.  34. 


CHANGES    IN    THE    OPTIC    NERVE NEURITIS.  51 

foreshortened,  and  are  concealed,  just  beyond  its  edge,  in 
the  adjacent  retina  (PL  III.  4,  IV.  1,  V.  6).  The  veins 
commonly  now  present  some  enlargement,  often  considerable, 
and  the  arteries  are  narrowed.  They  may  be  indistinct 
upon  the  disc,  being  concealed  by  the  tissue.  The  arteries 
are  always  more  concealed  than  the  veins.  The  vessels  are 
often  lost  to  view  at  the  centre  of  the  swelling  (PL  I.  6, 
IV.  3,  V.  5),  although  there  may  be  a  depression  where  they 
emerge.  This  central  depression  is  sometimes  large,  in  con- 
sequence of  the  neuritic  swelling  being  chiefly  located  on  the 
edge  of  the  disc  (PL  VII.  1) — a  condition  which  has  been 
distinguished  as  "  perineuritis."  The  swelling  increases,  not 
only  in  height  but  in  lateral  extent,  and  partly  displaces, 
partly  invades,  the  adjacent  part  of  the  retina,  often  having 
a  diameter  two  or  three  times  that  of  the  optic  disc.  There 
are,  however,  rarely  signs  of  any  general  disturbance  of  the 
retina.  Extravasations  of  blood  may  occur  on  the  surface 
of  the  swelling,  and  not  uncommonly  white,  flake-like  spots 
may  appear  upon  it,  often  concealing  the  vessels  (PL  III.  3, 
IV.  1,  VI.  2).  Occasionally  a  white  spot  is  surrounded  by  a 
halo  of  haemorrhage  (PL  VI.  2).  Sometimes  similar  spots 
exist  in  the  retina  close  to  the  edge  of  the  disc. 

A  large  number  of  cases  proceed  no  farther  than  this  stage. 
Signs  of  passive  congestion  of  the  veins  may  or  may  not  be 
present.  If  not  present  before,  they  may  be  developed 
during  the  subsidence  of  the  neuritis,  especially  if  quick 
absorption  of  the  inflammatory  products  cannot  be  obtained. 
Neuritis  of  this  stage  may  clear  completely  (PL  IV.),  the 
inflammatory  products  being  for  the  most  part  removed,  and 
those  which  remain  merely  causing  a  little  increase  of  tissue 
in  the  middle  of  the  disc.  The  subsidence  is  marked  by  a 
diminution  in  the  height  and  extent  of  swelling,  and  in  its 
redness.  At  first  it  may  appear  somewhat  more  opaque 
(PL  VI.  3),  but  becomes  less  so  as  the  swelling  subsides. 
The  position  of  the  edge  of  the  choroid  becomes  appreciable, 
and  gradually  clearer,  first  on  the  temporal,  and  then  on  the 
nasal  side.  The  disc  has  a  "  filled  in  "  aspect  (PL  VI.  5), 
and  both  arteries  and  veins  may  be  narrowed  and  partly 


52  MEDICAL    OPHTHALMOSCOPY. 

concealed  on  its  surface.  This  is  especially  the  case  when 
the  new  tissue-elements  in  the  disc  have  been  sufficiently 
abundant  to  develop  signs  of  strangulation  during  the  in- 
flammatory stage  (PL  VI.  1  and  VIII.  1).  When  this  is 
not  the  case,  as  in  PL  III.  5  and  6,  IV.  1  and  2,  the  disc 
may  rapidly  clear  in  the  centre,  as  well  as  in  the  periphery, 
and  the  physiological  cup  be  quickly  reproduced.  Often, 
however,  white  lines  along  the  vessels  indicate  the  remnants 
of  preceding  inflammation  (PL  IV.  2,  II.  4),  and  the  vessels 
may  be  a  little  narrowed.  Commonly,  when  the  inflamma- 
tory swelling  has  been  marked,  a  disturbance  of  the  pigment- 
epithelium  leads  to  a  narrow  zone  of  atrophy  adjacent  to 
the  disc  (PL  II.  4,  IV.  4). 

Whether  or  not  there  are  signs  of  mechanical  congestion  in 
the  stage  of  neuritis  just  described,  a  further  increase  in  the 
inflammation  is  invariably  accompanied  with  signs  of  com- 
pression of  the  vessels,  and  strangulation  of  the  inflamed 
papilla,  with  a  rapid  and  intense  increase  in  the  mischief. 
The  tumour  formed  by  the  swollen  papilla  becomes  much 
more  promiment,  and  extends  laterally  in  all  directions,  even 
as  far  on  the  temporal  side  as  the  macula  lutea.  The  form 
of  the  swelling  varies ;  sometimes  it  remains  conical,  but 
usually  the  sides  become  steeper,  and  the  top  more  or  less 
flattened.  The  sides  may  even  overhang  so  that  the  tumour 
has  a  fungiform  shape,  and  the  vessels,  as  they  pass  over  the 
side,  may  be  concealed  by  the  edge  of  the  SAvelling,  and 
reappear  in  the  fund  us  in  a  different  position.  Good 
examples  of  this  intense  strangulated  neuritis  are  represented 
on  the  next  page  (Figs.  6  and  7,  and  at  PL  VI.  1). 

The  arteries  are  much  narrowed,  and  often  altogether 
invisible  on  the  swelling,  being  buried  in  its  substance,  and 
appearing  first  in  the  retina,  a  little  distance  from  its  edge. 
The  veins  are  often  concealed  on  the  disc,  at  least  in  part, 
but  some  of  them  are  usually  visible  towards  the  edge  of  the 
swelling,  and  are  greatly  distended.  When  the  amount  of 
swelling  is  extreme,  all  the  vessels  may  be  concealed,  as  in 
PL  VI.  1.  Haemorrhages  are  frequent  and  extensive,  and 
are  commonly  situated  on  the  edge  rather  than  on  the 


CHANGES    IN    THE    OPTIC    NERVE NEURITIS. 


53 


surface  of  the  swelling  (PI.  VI.  1  and  VIII.  1).     The  over- 
hanging edge  may  be  infiltrated  with  blood.     The  veins  may 


FIG.  6.— ACUTE  OPTIC  NEURITIS  IN  A  CASE  OF  CEREBRAL  TUMOUR.  * 
There  are   great  swelling   of  the   disc,   which   is   surrounded    by   radiating 
haemorrhages,  and,  at   the   macula,   a  star-like    arrangement   of  white 
spots.   .  No  albuminuria,  and  no  history  of  syphilis. 


FIG.  7. — ACUTE  OPTIC  NEURITIS. 

The  veins  and  arteries  are  both  concealed  by  the  swelling.  The  veins  are 
distended,  while  the  arteries  are  narrowed.  Numerous  white  patches 
are  scattered  over  the  swollen  papilla. 

1  After  Edmunds,  "Trans.  Ophth.  Soc.,"  1884,  p.  291. 


54  MEDICAL    OPHTHALMOSCOPY. 

be  concealed  beyond  the  edge  of  the  swelling,  and  often 
present  many  curves  and  twists,  sometimes  corkscrew-like 
from  their  elongation.  The  tint  of  the  strangled  swelling 
is  usually  a  full  red,  mottled  and  streaked  from  enlarged 
vessels  and  small  extravasations.  The  striation  due  to  the 
nerve  fibres  is  commonly  lost.  The  retina  adjacent  is  often 
the  seat  of  haemorrhages,  which  may  extend  along  the  vessels 
from  the  disc.  Not  unfrequently  secondary  changes  occur  in 
the  retina  over  a  wide  extent.  Haemorrhages,  usually  striated 
and  situated  in  the  nerve-fibre  layer,  may  be  scattered 
over  the  whole  fundus  (PI.  VI.  1).  The  veins  are  often 
distended,  and  may  be  tortuous  for  a  long  distance  from  the 
disc.  The  ultimate  distension  of  the  veins  may  be  as  great 
in  the  papillitis  which  succeeds  a  descending  neuritis  (see 
Pigs.  18,  23,  &c.)  as  in  that  which  is  supposed  to  be  limited  to 
the  eye.  The  retina,  in  rare  cases,  presents  areas  of  opacity, 
diffuse  and  cloudy,  or  localized  and  white,  and  often  occur- 
ring along  the  course  of  the  vessels  (PL  VIII.  1).  When 
the  swelling  of  the  retina  is  very  intense  it  may  become 
thrown  into  folds.  On  examining  such  an  eye,  bright  streaks 
will  be  seen  running  in  different  directions,  frequently 
arranged  radially  around  the  macula,  probably  due  to  the 
reflection  of  the  light  from  the  summit  of  the  folds. 

The  time  taken  for  the  development  of  these  changes  varies 
within  wide  limits.  A  neuritis  may  remain  for  months  and 
even  years  in  the  slighter  degree,  or  most  intense  strangula- 
tion may  be  developed  in  a  few  weeks. 

Subsidence  of  Neuritis. — The  gradual  subsidence  of  the 
slighter  degrees  of  neuritis  has  been  already  traced.  In  the 
more  intense  forms,  in  which  strangulation  has  occurred, -the 
stage  of  subsidence  presents  certain  peculiar  features.  The 
venous  distension  gradually  lessens  after  the  strangulation  has 
existed  for  a  time,  and  the  veins  may  become  narrow  before 
other  signs  of  strangulation  subside.  In  PL  VI.  1  they  are 
much  smaller  than  in  the  earlier  stage  of  strangulation  shown 
in  PL  VIII.  1.  This  is  probably  because  the  compression  of 
the  arteries  becomes  sufficient  to  lessen  the  blood-supply  to 
such  an  extent  as  to  permit  the  veins  to  recover  nearly  their 


CHANGES    IN    THE    OPTIC    NERVE NEURITIS.  55 

normal  calibre.  When  the  strangulation  is  less  intense,  the 
oommencement  of  subsidence  may  be  attended  with  an 
increase  in  the  mechanical  distension  of  the  veins,  and 
increased  narrowing  of  the  arteries.  The  redness  of  the 
swelling  lessens,  haemorrhages,  as  a  rule,  cease  to  occur,1  and 
some  of  the  blood  already  extravasated  disappears.  The 
tumour  lessens  in  height  and  in  extent,  and,  if  fungiform, 
again  becomes  conical  (PL  VI.  3).  The  highest  portions  of 
the  swelling  gradually  become  pale ;  the  sloping  sides  and 
adjacent  part  of  the  retina  may  present  a  darkish  dis- 
-coloration,  into  which  the  central  pallor  passes  gradually 
(PL  II.  1,  IV.  5,  V.  6,  VI.  3).  The  centre  of  the 
.swelling  soon  presents  a  distinct  depression,  from  which 
the  vessels  emerge  often  concealed  by  whitish  tissue.  Over 
the  swelling  the  course  of  the  veins  becomes  more  distinct. 
The  arteries  may  be  still  concealed,  their  more  rigid,  straight 
course  having  caused  them  to  be  buried  in  the  new  tissue 
more  deeply  than  the  veins,  which  were  pushed  up  before  it, 
and  the  paler  tint  of  the  arteries  also  renders  them  less  con- 
spicuous. The  concealment  of  the  veins  beyond  the  edge  of 
the  disc  is  even  greater  than  it  was  before,  in  consequence  of 
the  curve  of  the  inelastic  vessels  into  the  retina  being  increased 
:as  the  swelling  subsides  (PL  VI.  4  and  5).  Slowly  the 
pallor  increases  and  the  swelling  lessens,  although  the  con- 
striction of  the  vessels  may  increase,  in  consequence  of  the 
•cicatricial  contraction  of  the  newly-formed  tissue.  Occasion- 
ally, when  large  vessels  appear  on  the  papilla  during  the 
neuritis,  these  become  tortuous,  and  gradually  disappear 
during  subsidence  (PL  IV.  5).  As  the  white  area  narrows 
to  near  the  limits  of  the  disc,  the  edge  of  the  choroid  and 
sclerotic  appear,  dim'ly  at  first  (PL  VI.  4,  left  edge),  then 
more  distinctly.  The  disc  has  a  white  "  filled-in  "  look  (PL 
VI.  5,  VIII.  2),  the  vessels  are  constricted,  and  it  is  very 
long  before  any  central  depression  is  developed  on  the  disc, 
although  ultimately  the  contraction  of  the  fibrous  tissue,  as 
in  other  cicatrices,  proceeds  to  an  extreme  degree,  and  the 

1  Very  rarely  fresh  haemorrhages  form  adjacent  to  the  papilla  during  the 
:  stage  of  subsidence,  as  in  PI.  VI.  4. 


56  MEDICAL    OPHTHALMOSCOPY. 

disc  may  again  become  hollow  (PI.  IV.  6).  The  lamina 
cribrosa  is,  however,  usually  permanently  veiled,  an  important 
characteristic  of  this  form  of  atrophy.  The  retinal  pigment 
and  choroid  are  frequently  disturbed  near  the  disc,  and  a 
zone  of  irregular  pigmentation  with  slight  choroidal  atrophy 
is  left,  causing  the  disc  to  have  irregular  edges,  but  this  zone- 
is  not  always  proportioned  to  the  amount  of  inflammatory 
disturbance,  and  if  slight  the  disc  may  ultimately  come  to 
have  a  clean-cut  edge.  At  first  the  disc  is  usually  very 
white,  rarely  grey,  with  white  lines  along  the  vessels  (PL  II. 
2,  upper  half).  When  it  has  reached  the  retinal  level, 
however,  although  it  may  appear  white  to  the  indirect 
image,  a  faint  grey  tint  is  usually  perceptible  on  direct 
examination,  and  as  the  contraction  increases  this  grey  tint 
becomes  more  marked,  and  the  ultimate  appearance  of 
the  disc  is  usually  distinctly  grey  to  direct  examination, 
although  often  white  to  indirect  examination.  Very  rarely 
the  inflammation  may  subside  irregularly,  clearing  from  one 
part  of  the  disc,  while  the  other  still  presents  the  characters 
of  neuritis  (PI.  II.  2). 

The  retina  undergoes  certain  changes  during  this  period  of 
subsidence.  Haemorrhages  upon  it  are  usually  soon  absorbed, 
but  sometimes  undergo  transformation  into  spots  of  pigment. 
Some  extravasations  lead  to  the  formation  of  white  spots  in 
the  retina.  This  is  especially  the  case  near  the  disc,  where 
the  nutrition  of  the  retina  is  always  a  good  deal  disturbed  by 
the  adjacent  inflammation.  These  white  spots,  which  depend 
on  fatty  degeneration,  either  of  fibrin  or  of  the  retinal 
elements,  and  persist  after  the  blood  has  been  removed, 
commonly  originate  close  to  the  borders  of  the  neuritic 
swelling ;  but  as  the  latter  subsides  and  contracts,  they  are 
left  behind,  and  are  often  one  or  two  discs'  breadth  from  the 
edge  of  the  sclerotic  ring,  and  they  may  then  puzzle  the 
observer  from  their  resemblance  in  character  and  position  to 
the  spots  of  albuminuric  retinitis.  A  group  of  such  spots,  mid- 
way between  the  disc  and  macula  lutea,  is  seen  in  PI.  VI.  -3. 
The  degenerative  changes  which  occur  when  the  inflammation 
is  very  intense,  and  of  wide  extent,  may  leave  an  appearance 


CHANGES    IN    THE    OPTIC    NERVE NEURITIS.  57 

strikingly  similar  to  that  of  the  albuminuric  affection.  If  the 
swelling  approaches  the  macula,  degeneration  occurs  among 
the  radiating  fibres  of  the  fovea  ceutralis,  causing  spots 
identical  in  appearance,  and  probably  in  nature,  with  those 
which  in  renal  disease  form  the  familiar  stellate  figure  around 
the  macula.  A  striking  instance  of  this  is  shown  in  PI. 
VIII.  2.  The  distinction,  as  will  be  subsequently  explained, 
consists  mainly  in  the  evidence  the  disc  affords  of  a  consider- 
able antecedent  neuritis.  Frequently,  as  the  retina  becomes 
atrophied,  slight  pigmentary  deposit  takes  place  in  it,  espe- 
cially around  the  macula  lutea,  and  sometimes  the  atrophy 
is  accompanied  by  wide-spread  slight  disturbance  of  the 
pigment-epithelium . 

When  a  neuritis  has  lasted  a  long  time,  and  the  veins  have 
been  persistently  stretched  over  the  swelling,  they  may  be  so 
permanently  elongated  that  the  subsidence  of  the  neuritis, 
instead  of  being  attended  with  a  diminution  in  their  tortuosity, 
is  accompanied  by  an  increase  in  their  curves.  This  is  shown 
in  PI.  VL  4  and  5,  in  which  also  a  very  rare  circumstance 
is  presented — the  occurrence  of  recent  extensive  hemorrhages 
during  the  stage  of  subsidence. 

Second  Attacks  of  Neuritis. — If  a  disc  has  become  com- 
pletely atrophied  it  is  very  rarely  again  the  seat  of  inflam- 
mation. In  one  case,  however,  of  a  boy  aged  twelve  (under 
the  care  of  Dr.  Hughlings-Jackson),  who  had  double  optic 
atrophy,  and  absolute  blindness  due  to  intra-cranial  disease 
some  years  previously,  distinct  double  papillitis  occurred  in 
the  atrophied  discs,  associated  with  symptoms  of  intra-cranial 
tumour.  When,  however,  atrophy  is  partial  or  absent,  in 
rare  *cases  two  attacks  of  neuritis  may  occur.  In  one  case, 
for  instance,  a  patient  suffered  without  doubt  from  a  cerebral 
tubercle,  and  died  from  an  attack  of  tubercular  meningitis. 
The  former  had  probably  become  quiescent,  and  the  neuritis 
which  it  caused  subsided,  leaving  partial  atrophy.  The  discs 
again  became  swollen  and  obscured  with  the  symptoms  of 
meningitis. 

PATHOLOGICAL  ANATOMY. — In  the  condition  described  as 


MEDICAL    OPHTHAJJ1OSCOPY. 


"  congestion  with  oedema,"  the  microscope  reveals  less  pro- 
minence than  was  observed  during  life,  because  the  swelling 


FIG.  8.— OPTIC  NEURITIS  ;  NERVE-FIBKE  LAYER. 

The  fibres  are  separated  by  numerous  round  and  oval  spaces,  due  to  cedema. 
The  nuclei  are  unduly  numerous,  and  lie  in  groups,  which  indicate  the 
fasciculi,  (x  150.) 


FIG.  9. — SECTION  THROUGH  THE  OUTER  PART  OF  AN  INFLAMED  PAPILLA. 

(a)  Pigment-epithelium,  (b)  Layer  of  rods  and  cones,  (c,  d)  The  nuclear 
layer,  (e)  The  inner  molecular  layer.  (/)  Ganglionic  cell  layer,  (g)  The 
greatly  swollen  nerve-fibre  layer,  containing  many  leucocytes,  many  of 
them  surrounding  the  vessels,  (x  150.) 


CHANGES    IX    THE    OPTIC    NERVE NEURITIS. 


59 


depended  on  distended  vessels  and  effused  serum.  The 
nerve  fibres  are  separable  with  abnormal  readiness,  and 
are  divided  by  spaces  which  during  life  were  occupied 
by  serum  (Fig.  8).  The  fibres  themselves  may  present 
slight  varicosity.  There  is  no  increase  in  the  connective- 
tissue  elements,  and  there  are  no  products  of  degeneration 
of  the  nerve  fibres.  The  retina  is  normal  to  the  edge  of  the 
ohoroid,  its  nerve-fibre  layer  being  alone  increased  in  thick- 
ness by  the  conditions  mentioned  as  causing  the  swelling  of 
the  papilla.  Sometimes  the  retinal  layers  may  be  displaced 
outwards  a  short  distance. 

In  the  stage  of  developed  neuritis  (Figs.  16 — 21,  &c.), 
the  microscope  reveals  a  considerable  swelling  of  the 
papilla,  often  two  or  three  millimetres  above  the  level  of  the 


FIG.  10. — SECTION  THROUGH  AN 
ARTERY  AND  VEIN  IN  THE  SAME 
PAPILLA. 

(a)  Distended  vein  ;  (b)  contracted 
artery  with  thick  walls. 


FIG.  11.— OPTIC  NEURITIS;  COL- 
LECTION OF  LEUCOCYTES  IN  A 
PERIVASCULAR  SPACE,  (x  150.) 


FIG.  12. — SECTION  THROUGH  AN  INFLAMED  PAPILLA. 

The  vessels  are  distended  with  corpuscles,  and  several  of  them  surrounded 
by  leucocytes.  The  nerve  fibres,  separated  by  oedema-spaces,  course 
upward  and  to  the  left,  and  at  right  angles  to  them  are  seen  some 
fine  connective-tissue  (supporting)  fibres.  (  x  120.) 


60  MEDICAL    OPHTHALMOSCOPY. 

choroid.  There  is  usually  a  central  depression,  which  may  be 
larger  and  deeper  than  the  ophthalmoscopic  examination  sug- 
gested. The  swelling  may  be  very  distinct  to  naked-eye  exa- 
mination (Figs.  27,  28,  p.  65),  and  haemorrhages  may  be  seen 
upon  it.  Thus,  mere  inspection  of  the  fundus  after  removal 
may  show  the  previous  existence  of  papillitis.  The  swelling  is 
due  to  several  conditions,  the  relative  degree  of  which  varies 
much  in  different  cases  : — (1)  The  vessels,  large  and  small, 
are  distended  with  blood  (Fig.  12).  (2)  Spaces  between  the 
nerve  fibres  sometimes  indicate  the  persistence  of  oedema 
(Fig.  8).  (3)  Many  nuclei  are  seen,  some  of  which  are 
leucocyte-like  corpuscles,  most  abundant  around  the  vessels, 
which  may  be  encrusted  by  a  thick  layer  (Figs.  9/r,  11,  12«, 
&c.);  they  are  sometimes  grouped  into  dense  masses 


FIG.  13. — GRANULE-CORPUSCLES,  &c. 

From  the  substance  of  the  papilla  in  a  case  of  optic  neuritis.     (Glycerine 
preparation;    x  100.) 


FIG.  14. — VARICOSE  NERVE  FIBRES 
From  an  inflamed  papilla  in  a  case  of  tubercular  meningitis.     (  x  200.] 


FIG.  15. — DEGENERATION  OF  NERVE  FIBRES. 

From  the  substance  of  an  inflamed  papilla  in  a  case  of  tumour  of  the  lower 
part  of  right  middle  cerebral  lobe.  Highly  magnified.  (After  Pagen- 
stecher  and  Genth.) 


CHANGES    IX    THE    OPTIC    NERVE NEURITIS. 


61 


{Figs.  9  and  17).  Similar  corpuscles  lie  in  greatly  increased 
numbers  between  the  bundles  of  nerve  fibres.  Some  of  these 
are  nuclei  belonging  to  a  system  of  connective-tissue  fibres 
which  run  at  right  angles  to  the  nerve  fibres  (indicated 
in  Figs.  8  and  11).  These  fibres  may  be  themselves 
swollen.  (4)  The  nerve  fibres  present  changes,  which 
contribute,  in  varying  degree,  to  the  production  of  the 
swelling.  They  are  irregularly  thickened,  and  the  enlarge- 
ments may  be  varicose,  moniliform,  or  knob-like  (Fig.  14), 
often  containing  granules  or  fatty  globules  from  degenera- 
tion of  the  myelin.  The  swellings  may  attain  a  large 
size,  as  in  the  accompanying  figure  (Fig.  15).  Free 
aggregations  of  fatty  globules  and  granules  may  also  be 
found,  commonly  enclosed  in  a  cell  wall  ("  granule-cor- 
puscles ")  (Fig.  13) ;  they  may  assume  a  colloidal  appear- 
ance ("corpora  amylacea  ").  Many  of  these  are  simply 


OPTIC  NEURITIS  IN  A  CASE  OF  CEREBRAL  TUMOUR. 

FIG.  16. — Section  through  the  centre  of  the  papilla,  showing  the  swelling 
of  the  outer  part  and  a  cential  depression,  almost  to  the  choroidal 
level.  The  nerve  fibres  can  still  be  traced,  separated  by  leucocytes. 
The  same  infiltration  is  to  be  seen  in  the  nerve.  The  sheatk  is  not 
distended,  but  its  lining  membrane  is  infiltrated  with  leucocytes. 


FIG.  17 — The  same  papilla  near  the  edge.     On  the  left  the  deeper  layers  of 
the^retiua  are  seen  thrown  into  folds.     (See  p.  64.) 


62  MEDICAL    OPHTHALMOSCOPY. 

the  detached  degeneration-swellings  of  the  nerve  fibres. 
They  are  best  seen  in  glycerine  preparations.  These 
products  of  degeneration  give  rise,  by  their  aggregation, 
to  the  larger  white  spots  seen  with  the  ophthalmoscope. 
(See  Fig.  7.)  Other  spots  are  apparently  due  to  aggrega- 
tions of  leucocytes. 

The  vessels  may  have  their  walls  thickened  by  nucleated 
tissue,  and  sometimes  by  a  clear,  finely  fibrillated  substance 
(Fig.  22). 

The  vessels  do  not  usually  present  any  evidence  of 
compression  in  the  sclerotic  ring,  but  commonly  appear  to 
be  narrowed,  often  considerably,  in  the  thickest  part  of  the 
swelling,  and  the  veins  are  again  enlarged  as  they  pass 
down  the  sides.  The  veins  are  usually  very  large,  the 
arteries  narrow.  The  former,  after  curving  down  the  sides  of 


FIG.  18. — SECTION  OF  THE  PAPILLA  IN  A  CASE  OF  CEREBRAL  TUMOUR. 

There  is  considerable  swelling,  greater  on  one  side.  The  commencement  of 
the  retina  is  displaced  some  distance  from  the  edge  of  the  sclerotic 
ring.  Infiltration  of  leucocytes  in  the  papilla  and  nerve-sheath ,  but  the 
latter  not  distended.  (  x  20.) 


FIG.  19. — SECTION  THROUGH  THE  MIDDLE  OF  THE  SAME  Disc. 

The  central  depression  remains,  although  much  narrowed.  The  central 
vein  is  seen  divided  longitudinally.  Neither  in  the  sclerotic  ring  nor 
behind  it  does  the  vein  present  any  trace  of  compression,  (x  8.) 


CHANGES    IX    THE    OPTIC    NERVE NEURITIS. 


63 


the  swelling,  descend  into  the  substance  of  the  swollen  retina, 
even  into  the  nuclear  layers,  and  rise  again  into  the  layer  of 
the  nerve  fibres.  Sometimes  two  such  curves  may  exist  (Fig. 
23).  The  retina  is  displaced  from  the  edge  of  the  choroid, 
often  as  far  as  a  millimetre  from  the  sclerotic  ring.  Its  layers 
at  the  commencement  usually  present  considerable  change. 
The  nerve-fibre  layer  is  thickened  by  a  slighter  degree  of 
the  changes  which  cause  the  swelling  of  the  disc.  The 
nuclear  layers  are  increased  in  thickness  and  often  blended 
together,  and  the  nuclei  more  or  less  separated  and  grouped 


FIG.  21. 

FIG*.  20  AND  21. — SECTIONS  THROUGH  THE  PAPILLA  iy  A  CASE  OF  OPTIC 
NEURITIS  DUE  TO  CHRpxic  CEUEBUITIS. 

(Case  published  by  Dr.  H.  Jackson  in  "  Ophth.  Hosp.  Rep.,"  vol.  viii.  p. 
445. )  The  papilla  is  slightly  swollen,  and  has  displaced  the  retinal  layers. 
In  Fig.  20  a  vein  is  seen  becoming  compressed  in  passing  through  the 
inflamed  retina,  but  it  will  be  noted  that  in  Fig.  21  there  is  no  sign  of 
compression,  as  the  central  nerve  passes  through  the  sclerotic  ring. 
(  x  15.)  See  also  chapter  on  "  Softening  of  the  Brain." 


Fie.  22. — PART  OF  A  SECTION  OF  AX  INFLAMED  PAPILLA  IN  A  CASE  OF 
OPTIC  NEURITIS. 

An  artery  (below)  and  a  vein  (above)  exhibit  thickening  and  fibrillation  of 
their  outer  coats.  Below  is  a  small  vessel  showing  similar  changes.  The 
surrounding  tissue  is  infiltrated  with  leucocytes.  (  x  100.) 


64 


MEDICAL    OPHTHALMOSCOPY. 


into  vertical  columns  by  the  displaced  fibres  of  Muller  (Fig. 
9).  The  retina  may  present  (as  here)  slight  curves  due  to 
its  displacement,  most  marked  in  its  outer  (deepest)  layers, 
and  effecting  detachment  of  the  retina,  the  space  between  the 
bacillary  layer  and  choroid  being  occupied  by  serum.  These 
curves  may  be  visible  with  the  ophthalmoscope  as  pale  bands, 
parallel  to  the  edge  of  the  papilla  (PI.  VII.  1). 


Fio.  23. — SECTION  THROUGH  THE  SWOLLEN  PAPILLA  IN  A  CASE  OF 
OLP  CHRONIC  MENINGITIS,  WITH  INFLAMMATORY  GROWTHS  IN  THE 
CONVEXITY  OF  THE  BRAIN.  (See  PI.  VI.  2  and  Fig.  33.) 

At  the  edge  of  the  swelling  a  large  vein  forms  two  vertical  curves  iu  the 
substance  of  the  thickened  retina,  the  lower  curve  reaching  the  inner 
nuclear  layer.  The  retinal  layers  are  displaced.  On  the  right  side  the 
pigment-epithelium  has  disappeared  in  the  portion  from  which  the 
retina  has  been  pushed  away  ;  on  the  left  side  the  epithelium  persists 
in  this  situation,  (x  15.) 


FIG.  24. — SECTION  THROUGH  THE  RETINA, 

Some  distance  from  the  disc  in  the  same  case.  The  vein  occupies  two-thirds 
of  the  thickness  of  the  retina,  and  in  one  or  two  places  has  encroached  on 
the  nuclear  layers.  (  x  50. ) 


FIG.  25.— SECTION  THROUGH  A  HEALTHY  OPTIC  NERVE. 
For  comparison  with  the  subsequent  figures. 


CHANGES    IN    THE    OPTIC    NERVE NEURITIS. 


65 


The  pigment-epithelium  may  persist  up  to  the  edge  of 
the  sclerotic,  or  it  may  disappear  in  the  area  from  which 
the  retina  has  been  displaced  (Fig.  23).  Often  the 
choroid  undergoes  atrophy  close  to  the.  edge  of  the 
sclerotic. 

The  changes  in  the  papilla  always  become  much  slighter  at 
the  sclerotic  ring,  and  may  appear  to  cease  there.  Commonly, 
however,  large  numbers  of  nuclei  lie  among  the  nerve  bundles 
in  and  just  behind  the  lamina  cribrosa,  where  such  nuclei  are 
in  health  most  abundant.  The  sclerotic  ling  may  appear 
distended,  the  nerve  tissue  occupying  closely  its  funnel-shaped 
area.  The  appearance  of  distension  is  partly,  if  not  entirely, 


FIG.  26. — TRANSVERSE  SECTION   THROUGH   THE   OPTIC  NERVE   HALF  AN 

INCH  BEHIND  THE  EYE. 

In  a  case  of  early  optic  neuritis.     Thickening  and  infiltration  of  sheath. 
Very  little  change  at  present  in  the  nerve.     ( x  150.) 


FIG.  27.  FIG.  28. 

POSTERIOR  SEGMENT  OF  EYEBALL  AND  OPTIC  NERVE. 
From  a  case  of  chronic  traumatic  meningitis,  showing  the  distension  of  the 
sheath  of  the  nerve  and  the  swelling  of  the  papilla.     (Natural  size,  after 
Pagenstecher  and  Genth.) 

F 


66 


M  fc'-DICAL    OPHTHALMOSCOPY. 


due  to  the  shape  of  the  ring,  as  may  be  seen  by  comparing 
Fig.  17  with  Fig.  23.  In  the  latter  the  appearance  of 
excavation  of  the  edge  of  the  sclerotic  is  present  on  the 
right  side  only,  and  an  interval  exists  between  it  and 
the  nerve  fibres,  occupied  only  by  the  fibres  of  the  lamina 
cribrosa. 

The  sheath  of  the  optic  nerve  is  often  distended  with 
fluid,  sometimes  slightly,  sometimes  considerably.  The  dis- 
tension is  greatest  a  short  distance  behind  the  eye,  and 
narrows  close  to  the  sclerotic,  having  thus  a  pyriform  shape 
(Fig.  27).  In  cases  of  old  neuritis  the  sheath  may  be 
enlarged  but  empty,  showing  previous  distension.  Micro- 
scopically the  nerve  may  appear  normal,  the  nuclear  increase 
near  the  lamina  cribrosa  being  absent  farther  back.  More 
commonly  signs  of  inflammation  may  be  traced  throughout 
the  nerve  ;  the  nuclei  are  increased  in  quantity,  its  trabeculae 
thickened  and  the  vessels  distended  (Figs.  29  and  30). 
The  inner  sheath  is  often  crammed  with  nuclei,  and  the 
connective  tissue  between  the  inner  and  outer  sheath 
increased  (Fig.  26).  The  nerve  fibres  may  present  evi- 
dence of  degeneration  (Figs.  29  and  30).  These  changes, 
slight  or  considerable,  may  often  be  traced  back  as  far  as 
the  chiasma,  in  front  of  which  they  are  sometimes  much 


' 

^^^ 


Fiu.  29.  —SECTION  THROUGH  THE 
OPTIC  NERVE,  JUST  BEHIND  THE 
SCLEROTIC. 

<P1.  III.  3).  The  nerve  fibres  present 
only  an  irregular  granular  appear- 
ance, the  axis  cylinders  being  no 
longer  demonstrable.  The  sheath 
presents  many  compressed  nuclei, 
(x  120.) 


/^'^y ;  ^ 

a.  "•  x  i ad    •/  *•"  ~    *  '•••'  '*•'"• 

FIG.  30.  —  TRANSVERSE  SECTION 
THROUGH  THE  SAME  OPTIC  NERVE, 
JUST  IN  FRONT  OF  THE  COMMIS- 
SURE. 

The  sheath  of  the  nerve  (on  the  left) 
contains  dilated  vessels,  and  large 
numbers  of  leucocytes,  which  are 
also  very  abundant  in  the  inter- 
fascicular  septa,  (x  120.) 


CHANGES    IN    THE    OPTIC    NERVE NEURITIS. 


67 


more  intense  than  anteriorly,  and  are  most  intense  near  the 
surface  of  the  nerve.  This  is  seen  especially  in  cases  of 
meningitis,  and  affords  evidence  of  extension  of  inflammation 
from  the  meninges.  An  increase  of  nuclei  is  sometimes  to 
be  traced  into  the  chiasma,  and  even  into  the  optic  tract 
(Fig.  32),  where  the  corpuscles  may  even  be  aggregated 
into  groups  that  have  been  termed  "miliary  abscesses" 
(Fig.  33). 

During  the  progressive  subsidence  to  atrophy,  there  is  a 
diminution  of  the  cellular  elements  in  the  papilla,  probably, 
in  part,  in  consequence  of  their  transformation  into  fibres. 
The  products  of  the  degeneration  of  the  nerve  fibres  are 
slowly  removed.  Ultimately  the  substance  of  the  papilla 
appears  to  consist  of  a  felty  mass  of  interlacing  fibres 
sprinkled  with  nuclei,  in  which  at  last  scarcely  any  indica- 
tion of  nerve  fibres  is  to  be  traced. 

SYMPTOMS. — Subjective  symptoms  may  be  entirely  absent, 

FIG.  31. — LONGITUDINAL  SECTION  OF  THE  OPTIC  NERVE,  FROM  A  CASE  OF 
OPTIC  NEURITIS, 

Showing  the  irregular  outline  of  the  degenerating  nerve  fibres,  and  the 
infiltration  of  leucocytes  between  the  fasciculi,  (x  120.) 


*&  ;li 

|p         mm 

FIG.  32. — LONGITUDINAL  SECTION 
THROUGH  THE  OPTIC  TRACT,  IN 
A  CASE  OF  OPTIC  NEURITIS. 

There  is  increase  in  the  connective 
tissue  corpuscles  between  the 
fibres  (  x  150.) 


FIG.  33.— SECTION  THROUGH  THE 
OPTIC  TRACT  IN  A  CASE  OF 
CHRONIC  MENINGITIS. 

Shows  aggregation  of  leucocytes  into 
a  "miliary  abscess,"  such  as  is 
seen  in  the  medulla  in  cases  of 
hydrophobia  (x  100.) 


68 


MEDICAL    OPHTHA.LMO3COPY. 


even  when  the  inflammation  of  the  papilla  is  of  considerable 
intensity,,  as  was  first  pointed  out  by  Hughlings-Jackson. 
Vision  may  be  unimpaired — acuity  and  colour-vision  being 
perfect,  and  the  field  unrestricted.  An  increase  in  the 
size  of  the  blind  spot  may  usually  be  ascertained  by 
mapping  it  out  with  the  perimeter,  but  of  this  the  patient 
is  unconscious.  The  degree  of  neuritis  which  may  exist, 
with  no  impairment  of  acuity  of  vision,  is  remarkable. 
In  the  cases  shown  in  PL  I.  4,  6,  III.  5,  IV.  1,  3,  V.  1, 
2,  VI.  4  and  5,  when  the  drawing  was  made,  the  acuity 
of  vision  was  scarcely  or  not  at  all  impaired.  It  is 
often  said  that  "  descending  neuritis  "  causes  much  earlier 
affection  of  sight  than  limited  intra-ocular  papillitis.  But 
acuity  of  vision  may  be  unimpaired  even  with  a  considerable 
degree  of  descending  neuritis.  In  more  intense  cases,  how- 
ever, sight  is  impaired  or  lost,  and  this  constitutes  the  chief 
subjective  symptom.  Photophobia  and  pain  in  the  eye  are 
very  rare  in  optic  neuritis.  Pain  in  the  head  may  occur  in 
cases  of  apparently  primary  papillitis  :  it  is,  of  course,  a  very 
common  accompaniment  of  symptomatic  inflammation,  but 


FIG.  34. — DIAGRAM  OF  THE  FIELD  OF  VISION  IN  A  CASE  OF  SUBSIDING 
OPTIC  NEURITIS  IN  CEREBELLAR  TUMOUR,  LEFT  EYE. 

The  outer  boundary  of  the  figure  is  the  limit  of  the  average  normal  field. 
Vision  was  lost  in  the  shaded  area,  preserved  only  within  the  inner  line 
around  the  fixing  point,  the  position  of  which  is  indicated  by  the 
asterisk. 


CHANGES    IN    THE    OPTIC    NERVE NEURITIS.  69 

is  then  generally  to  be  accounted  for  by  the  intra-cranial 
disease. 

The  affection  of  vision  usually  occurs  earlier  in  the  one  eye 
than  it  does  in  the  other.  It  may  come  on  rapidly  or  slowly  5 
never  suddenly.  Sometimes  the  rapidity  of  its  progress  may  be 
great ;  sight  may  fail  completely  in  the  course  of  a  few  days. 

Restriction  of  the  visual  field  usually  accompanies  con- 
siderable change  in  the  acuity  of  vision.  It  may  be  ex- 
tensive, and  often  reaches  its  height  during  the  stage  of 
subsidence.  Only  a  small  area  around  the  fixing  point 
may  remain,  as  in  the  diagram  (Fig.  34),  from  a  case  of 
subsiding  neuritis  in  cerebellar  tumour.  Occasionally  the 
limitation  of  the  field  of  vision  may  be  irregular,  one  part 
being  more  or  less  affected  than  the  rest,  as  in  Fig.  35, 
in  which  the  upper  part  only  is  restricted.  In  some  cases 
a  change  in  the  field  of  vision,  due  to  the  intra-cranial 
disease,  may  accompany  the  peripheral  limitation  due  to  the 
optic  neuritis,  as  in  the  diagrams  (Figs.  36  and  37)  of  the 
fields  of  vision  in  a  case  in  which  hemianopia,  owing  to  the 
intra-cranial  disease,  accompanied  the  peripheral  limitation. 


FIG.   35. — DIAGRAM   OF  FIELD  OF  VISION,   SHOWING  LIMITATION 
ABOVE  ONLY, 

From  a  case  of  unilateral  optic  neuritis,  probably  due  to  cerebral  syphiloma. 
There  was  amblyopia,  but  no  neuritis  of  the  other  eye.  Both  discs 
subsequently  became  atrophied. 


70 


MEDICAL    OPHTHALMOSCOPY. 


Not  unfrequently  there  is  marked  peripheral  amblyopia,  and 
a  small  object  cannot  be  recognized  in  the  periphery,  although 
a  large  object,  as  the  hand,  is  well  seen.  The  increase  in  size 
of  the  blind  spot  is  proportioned  to  the  size  of  the  papillary 
swelling.  The  accompanying  diagram  (Fig.  38)  shows  its 
area  in  a  case  of  optic  neuritis  figured  in  PI.  IV.  3.  It  is  a 
little,  but  not  much,  larger  than  normal. 

When  there  is  distinct  amblyopia  there  may  be  a  defect  in 


RIGHT 


LEFT 

FIG.  36.  FIG.  37. 

DIAGRAMS  OF  THE   FIELDS  OF  VISION  IN  A  CASE  OF  HEMIANOPIA  AND 
DOUBLE  OPTIC  NEURITIS. 

Probably  due  to  a  cerebral  syphiloma.  The  asterisk  represents  the  fixing  point, 
the  dot  the  position  of  the  blind  spot.  The  outer  boundary  of  the 
shading  is  the  normal  limit  of  the  field,  the  shading  the  area  in  which 
sight  was  lost.  There  is  seen  to  be  loss  of  the  whole  right  half  of  each 
field,  with  concentric  limitation  of  the  left  halves. 


FIG.  38. — DIAGRAM  OF  THE   BLIND   SPOT  (SHADED  AREA)  IN  A  CASE  OF 
OPTIC  NEURITIS. 

From  a  case  of  tumour  (probably  a  syphiloma)  in  the  left  ascending  parietal 
convolution  (see  also  PI.  IV.  3). 


CHANGES    IN    THE    OPTIC    NERVE NEURITIS. 


71 


colour- vision,  and  the  latter  may  exist  even  when  acuity  of 
vision  is  very  little  impaired.  The  order  of  loss  is  sometimes 
(as  in  atrophy,  q.  v.}  that  of  the  normal  peripheral  arrange- 
ment of  the  colour  fields  in  the  accompanying  figure  (Fig.  39), 
red  and  green  being  lost  before  yellow  and  blue.  Thus  in  a 
case  under  the  late  Dr.  Radcliffe,  of  a  girl  aged  eleven, 
who  had  optic  neuritis  of  both  eyes,  there  was  little  limita- 
tion of  the  field  for  white.  The  only  colour  which  she  could 
name  accurately  was  yellow.  Light  shades  of  other  colours 
were  called  white,  deep  shades  black.  More  frequently, 
however,  the  loss  is  irregular.  In  three  cases  I  have  seen 
yellow  alone  lost.  In  a  case  of  severe  neuro-retinitis  due  to 
chlorosis,  at  one  time,  yellow  was  alone  lost  in  one  eye,  and 
in  the  other  eye  yellow,  blue,  and  green  were  lost,  red  being 
seen ;  and  recovery  was  in  the  order  of  the  fields,  the  yellow 
last.  Now  and  then  colour- vision  may  be  little  affected, 
even  when  there  is  considerable  peripheral  limitation  of 
the  field  of  vision. 


FIG.  39. — DIAGRAM  SHOWING  THE  FIELDS  OF  COLOUR-VISION  IN  A  NORMAL 
EMMET ROPIC  EYE  ON  A  DULL  DAY.1 

The  fields  are  each  rather  smaller  than  on  a  bright  day.  The  asterisk 
indicates  the  fixing  point,  the  black  dot  the  position  of  the  blind  spot. 
(Usually  the  blue  field  is  larger  than  the  yellow. )  See  the  section  on 
"Atrophy  of  the  Optic  Nerve." 

1  I  am  indebted  to  Mr.  Nettleship  for  the  charts  from  which  this  diagram 
was  made. 


72  MEDICAL   OPHTHALMOSCOPY. 

When  sight  is  completely  lost,  the  sensibility  of  the  retina 
to  electrical  stimulation  may  or  may  not  be  impaired.  It 
may  be  lost  during  blindness,  and  return  with  some  recovery 
of  sight. 

It  is  very  important  to  be  aware  as  far  as  possible  of  the 
mechanism  by  which  sight  is  impaired,  since  the  prognosis 
must,  in  the  main,  depend  thereon.  The  loss  of  sight  which 
occurs  in  cases  of  idiopathic  isolated  papillitis  is,  of  course, 
due  to  the  process  which  can  be  seen  with  the  ophthalmoscope. 
But  the  papillitis  which  occurs  in  intra-cranial  disease  may 
be  accompanied  with  loss  of  sight  due,  not  to  the  intra-ocular 
changes,  but  to  mischief  in  the  course  of  the  optic  fibres  or 
in  the  centres  with  which  they  are  connected.  The  first  point 
to  ascertain,  therefore,  is  whether  the  amblyopia  is  due  to 
the  intra-ocular  changes  or  to  mischief  farther  back.  It  is 
not  always  possible  to  determine  this  point,  but  very  often  an 
accurate  opinion  may  be  formed. 

Concomitant  affection  of  sight  from  intra-cranial  processes, 
it  may  be  thought,  should  be  more  frequent  in  cases  of 
descending  neuritis,  than  in  cases  of  supposed  isolated 
papillitis  ;  because  descending  neuritis  is  due  to,  and  involves, 
organic  changes  in  the  optic  path.  This  is  true,  but  this 
distinction  does  not  afford  much  assistance,  because  it  is  not 
often  that  we  can  rely  upon  the  ophthalmoscopic  distinction 
between  descending  and  isolated  neuritis. 

Another  distinction  is  derived  from  the  manner  in  which 
the  loss  of  sight  comes  on.  Blindness  from  optic  neuritis 
never  comes  on  suddenly ;  it  occasionally,  though  rarely, 
comes  on  suddenly  in  concomitant  brain  disease.  From  optic 
neuritis,  however,  as  just  stated,  it  may  come  on  in  the  course 
of  two  or  three  days.  More  important  indications  are 
derived  from  the  form  in  which  sight  is  lost.  A  symmetrical 
hemiopic  defect  in  the  field  (such  as  in  Figs.  36  and  37) 
means  an  intra-cranial  cause ;  and  unsymmetrical  lateral 
defect,  especially  a  loss  of  the  temporal  halves  (as  Figs.  40 
and  41),  ordinarily  means  pressure  on  the  chiasma,  a  very 
common  cause  of  blindness  in  these  cases,  the  pressure  being 
exerted  by  a  distended  third  ventricle.  Complete  loss  of 


CHANGES    IN    THE    OPTIC    NERVE NEURITIS. 


sight  of  one  eye,  and  loss  of  the  adjacent  half  of  the  other 
field  (as  in  Figs.  42  and  43),  is  hypothetically  of  cerebral 
origin.1  A  peripheral  restriction  of  the  fields  usually  means 


'-EFT  RIGHT 

FIG.  40.  FIG.  41. 

DIAGRAMS  or  THE  FIELDS  OF  VISION  IN  A  CASE  IN  WHICH  SIGHT  WAS 

PROBABLY    LOST    FROM    PRESSURE    ON    THE    CHIASMA. 

The  shaded  area  indicates  the  part  in  which  vision  was  lost — viz.,  the 
temporal  portions  of  both  fields, — the  nasal  portions  alone  persisting 
("temporal  hemianopia  "). 


RIGHT 

FIG.  43. 

DIAGRAMS  OF  THE  FIELDS  OF  VISION  IN  A  CASE  OF  Loss  OF  SIGHT  AND 
DISEASE  OF  THE  RIGHT  CEREBRAL  HEMISPHERE. 

Loss  of. the  whole  of  the  left  field  and  of  the  left  half  of  the  right,  with  a 
little  peripheral  defect  on  the  temporal  (right)  side. 

1  The  loss  may  be  explained  on  the  unproved  hypothesis  of  Charcot  that 
there  is  a  secondary  decussation  at  the  corpora  quadrigemina,  complementary 
to  the  approximate  semi-decussation  which  certainly  takes  place  at  the 
chiasma.  Thus  an  extensive  lesion  at  the  posterior  part  of  one  optic 
thalamus  would  destroy  the  fibres  which  had  crossed  to  that  side  at  both 
decussations  (i.e.,  all  from  the  opposite  eye)  and  those  which  were  about  to 
decussate  at  the  corpora  quadrigemina  from  the  eye  on  the  same  side.  The 
only  uninjured  fibres  would  be  those  from  the  inner  half  of  the  retina,  on  the 


74  MEDICAL    OPHTHALMOSCOFY. 

damage  in  front  of  the  optic  commissure,  and,  in  most  cases 
of  intra-ocular  neuritis,  damage  from  the  visible  changes. 
A  central  scotoma  is  observed  only  when  there  is  a  con- 
spicuous lesion  at  the  macula  lutea,  or  in  cases  of  primary 
retro-ocular  (axial)  neuritis. 

Lastly,  important  assistance  is  derived  from  the  degree  of 
intra-ocular  damage — is  it  sufficient  to  account  for  the  loss  of 
sight  ?  The  question  is  one  difficult  in  many  cases  to  answer, 
and  an  approximate  answer  can  only  be  afforded  by  a 
knowledge  of  the  conditions  on  which  the  loss  of  sight,  in 
these  cases,  depends.  The  study  of  intra-ocular  neuritis  in 
relation  to  affection  of  sight  makes  it  probable  that  vision 
may  suffer  in  two  ways,  apart  from  the  involvement  of  the 
retina.  The  first  is  damage  to  the  nerve  fibres  by  the  process 
of  inflammation  around  them.  We  know  that  acute  inflam- 
mation has  a  tendency  to  stop  the  conducting  power  of  nerve 
fibres,  apparently  by  some  direct  damage  to  their  finer  struc- 
ture, and  that  the  subsidence  of  the  inflammation  may  be 
followed  by  a  recovery  of  function.  The  second  is  by  pressure 
on  the  fibres  by  the  products  of  inflammation.  This  occurs 
both  during  the  inflammation  and  while  it  is  subsiding. 
During  subsidence,  the  newly-formed  elements  are  undergoing 
a  transformation  into  contracting  fibrous  tissue.  A  similar 
compression  probably  also  occurs  during  the  height  of  the 
inflammation,  from  the  excessive  amount  of  tissue  produced, 
because  at  that  period  loss  of  sight  may  often  be  observed  to 
coincide  with  a  marked  increase  in  the  '*  strangulation  "  of 
the  swollen  disc.  Damage  to  vision  from  compression  of  the 
fibres  during  subsidence  of  the  neuritis  is  very  common  and 
very  serious.  It  may  cause  considerable  damage  to  sight 
which  has  been  unimpaired  by  the  active  neuritis,  and  it  con- 
stantly succeeds  and  intensifies  impairment  by  inflammatory 
compression  during  the  active  stage.  The  amblyopia  which 
occurs  during  the  height  of  the  inflammation  may  lessen  as 
the  inflammation  subsides,  and  be  again  renewed  by  the  con- 
traction of  the  new  tissue  as  the  subsidence  of  the  swelling 

same  side  as  the  cerebral  lesion,  fibres  which  had  crossed  at  the  chiasma  to 
the  opposite  hemisphere. 


CHANGES    IN    THE    OPTIC    NERVE NEURITIS.  75 

advances.  The  latter  constitutes  by  far  the  greatest  danger, 
because  the  contraction  which  causes  it  continues,  and  increases 
for  a  long  time,  and  the  amblyopia  due  to  it  usually  continues 
and  increases  until,  and  even  after,  the  disc  has  reached  its 
normal  level.  The  progress  of  the  amblyopia  from  this 
cause  may,  however,  be  interrupted  by  the  recovery  of 
fibres  damaged  only  during  the  active  inflammatory  stage, 
and  when  the  amount  of  new  tissue  formed  is  small  in 
proportion  to  the  irritative  changes  in  the  disc  (as  in  many 
cases  of  syphilitic  disease  duly  treated),  a  considerable  in- 
flammatory amblyopia  may  clear  away  and  be  followed  by 
very  slight  consecutive  defect.  The  latter  is  usually  more  or 
less  permanent,  but,  after  it  has  reached  its  height,  consider- 
able subsequent  improvement  does,  in  some  cases,  slowly 
occur  (see  p.  130). 

Not  unfrequently  after  a  neuritis  has  subsided,  with  or 
without  impairment  of  vision,  a  further  loss  of  sight,  complete 
or  incomplete,  may  occur  from  intra-cranial  causes  without 
any  fresh  ophthalmoscopic  appearances.  It  will  thus  be  seen 
that  a  considerable  disparity  between  the  affection  of  sight 
and  the  course  of  the  papillitis  indicates  the  influence  of  retro- 
ocular  mischief.  A  good  illustration  of  this  is  afforded  by 
the  case  figured  in  PL  VII.  1  and  2,  in  which  the  papillitis 
was  unilateral,  the  other  eye  presenting  normal  characters 
throughout ;  but  the  sight  of  both  eyes  failed  after  the 
subsidence  of  the  papillitis  (see  Fig.  35). 

CAUSES. — The  most  common  causes  of  optic  neuritis  are 
encephalic  diseases,  and  of  these  tumour  is  incomparably  the 
most  frequent.  Neither  the  nature,  size,  nor  the  seat1  of  the 
tumour  appears  to  exercise  much  influence  on  the  occur- 
rence of  neuritis.  The  next  most  frequent  cause  is  certainly 

1  From  an  analysis  of  cases  made  by  Edmunds  and  Lawford  it  would  appeal- 
that,  ceteris  paribus,  tumours  near  the  convexity  of  the  brain  are  somewhat 
less  liable  to  cause  optic  neuritis  than  those  situated  near  the  base.  Cerebellar 
tumours  seemed  particularly  prone  to  excite  optic  neuritis,  often  of  a  severe 
type.  Of  twelve  cases  of  primary  tumour  of  the  cortical  motor  area,  on  the 
other  hand,  not  one  was  associated  with  optic  neuritis  ("Trans.  Ophth. 
Soc.,"  vol.  iv.  1884,  p.  172). 


76  MEDICAL    OPHTHALMOSCOPY. 

meningitis,  and  then  come  abscess  of  the  brain,  hydatid 
disease  of  the  brain,  and  softening  of  the  brain  from  vascular 
obstruction.  In  some  cases  it  appears  to  result  from  an 
irritative  process  in  the  brain,  revealed  only  by  the  micro- 
scope (see  Part  II.,  "  Inflammation  of  the  Brain").  It  also 
accompanies,  in  rare  cases,  acute  diseases  of  the  spinal  cord. 
Other  causes,  outside  the  nervous  system,  are — albuminuria, 
lead  and  tobacco  poisoning,  certain  febrile  diseases,  ansemia 
(especially  from  loss  of  blood),  and  certain  other  morbid  blood 
states.  It  may  probably  occur  as  an  idiopathic  affection, 
without  obvious  exciting  cause,  or  from  disturbances  of  men- 
struation, or  exposure  to  cold.  In  all  these  cases  it  is,  as  a 
rule,  double ;  now  and  then,  in  cerebral  disease,  and  after 
acute  febrile  diseases  and  loss  of  blood,  it  may  be  single. 
Unilateral  optic  neuritis  may  result  from  mischief  in  the 
posterior  portion  of  the  orbit — inflammation  or  growth 
invading  the  optic  nerve. 

In  the  general  diseases,  such  as  albuminuria,  lead  poisoning, 
ansemia,  &c.,  optic  neuritis  is  often  associated  with  encephalic 
symptoms.  In  a  case  of  lead  poisoning  (PL  VII.  6),  the 
neuritis  was  associated  with  great  mental  excitement,  and 
so  also  in  a  case  of  albuminuria  (PL  IX.  2),  while  in  the 
similar  case  figured  in  PL  IX.  3,  intense  headache  was 
present.  It  seems  probable  that,  in  these  cases,  either  the 
cerebral  disturbance  is  concerned  in  the  production  of 
neuritis,  or  the  neuritis  and  cerebral  disturbance  may  be 
the  indication  of  a  general  effect  of  the  toxaemia  on  the  nerve 
tissues. 

DURATION. — The  duration  of  optic  neuritis  varies  very 
much  in  different  cases.  The  cases  of  most  rapid  course  may 
reach  their  height  in  two  or  three  weeks,  maintain  it  for 
about  the  same  time,  and  then  subside.  These  are  of  two 
classes — the  most  trifling,  and  the  most  severe.  The  former 
are,  for  the  most  part,  those  which  depend  on  a  cerebral 
condition  which  soon  subsides,  such  as  a  transient  attack 
of  meningitis,  or  syphilitic  or  scrofulous  disease,  which  is 
influenced  by  treatment  before  the  neuritis  reaches  its  height. 


CHANGES    IN    THE    OPTIC    NERVE NEURITIS.  77 

Now  and  then,  however,  a  neuritis  rapidly  subsides,  although 
the  cerebral  disease  progresses.  But  this  is  the  rare  exception. 
In  these  transient  cases  the  subsidence  may  occupy  the  same 
time  as  the  development — two  or  three  weeks — and  be 
complete ;  so  that  at  the  end  of  six  or  eight  weeks  the  discs 
are  again  normal.  In  some  very  intense  cases,  such  as  that 
of  apparently  idiopathic  neuritis  figured  in  PL  VIII.,  the 
development  of  the  affection  may  be  equally  rapid,  an  intense 
degree  of  swelling  being  soon  attained,  and  subsidence 
commencing  in  a  few  weeks.  In  these  cases,  however, 
the  retrocession  of  the  neuritis  is  always  slow,  and  commonly 
occupies  many  weeks;  often  months  pass  before  the  edges 
of  the  disc  are  again  perceptible.  In  two  cases  of  cerebral 
abscess,  where  the  pus  was  evacuated  by  an  operation,  the 
neuritis,  which  was  extreme,  subsided  in  a  little  more  than 
a  fortnight. 

On  the  other  hand,  the  course  of  neuritis  may  be  so  chronic 
that  months,  even  a  year,  may  pass  without  the  least  change 
in  the  condition  of  the  discs  being  perceptible  (for  instances 
of  this  see  cases  23,  24,  and  26  in  former  editions  of  this 
book).  Most  cases  of  this  extreme  chronicity  that  have  come 
under  my  observation  have  accompanied  symptoms  of  brain 
disease  which  were  not,  in  themselves,  suggestive  of  "  coarse  " 
brain  disease,  tumour,  &c.  But  in  some  cases  an  equally 
chronic  neuritis  may  accompany  tumour.  That  shown,  for 
instance,  in  PI.  V.  1  and  2  presented  no  alteration,  tested  by 
comparison  with  the  drawing,  for  eighteen  months,  and  two 
years  later  was  still  marked,  the  red,  congested  half  being 
similar  in  area,  although  on  the  clearer  half  the  disc  had 
become  grey,  and  sight  was  lost.  It  is  to  be  noted  that  in 
this  case  the  symptoms  of  tumour,  although  intense,  also 
progressed  very  slowly,  and  the  chronicity  of  the  neuritis 
probably  may  be  taken  as  an  indication  of  chronicity  of  the 
cerebral  disease.  The  converse  proposition,  however,  that  all 
forms  of  very  chronic  brain  disease  entail  a  chronic  form  of 
neuritis,  does  not,  by  any  means,  hold  good. 

In  most  cases  the  duration  of  neuritis  is  intermediate 
between  the  extremes  mentioned,  reaching  its  height  in 


78  MEDICAL    OPHTHALMOSCOPY. 

a  month  or  two,  and  often  remaining  for  some  weeks  or 
months  with  little  change,  and  then  subsiding.  A  rapid 
strangulation  usually  precedes  subsidence  at  no  long  period, 
the  products  of  inflammation  perhaps  checking  the  inflam- 
matory process. 

THE  RELATION  or  OPTIC  NEURITIS  TO  ENCEPHALIC 
DISEASE. — The  first  definite  theory  of  the  mechanism  by 
which  intra-cranial  disease  acts  was  put  forward  by  von 
Grraefe  in  1859,1  and  further  developed  by  him  in  1866.-  It 
was  founded  on  the  observation  that  in  some  cases  of  intra- 
ocular neuritis,  with  haemorrhages,  in  cerebral  tumour,  no 
signs  of  inflammation  were  perceptible  on  naked-eye  exami- 
nation in  the  trunk  of  the  optic  nerve  ;  whereas,  in  a  case  of 
meningitis  in  which  the  ophthalmoscopic  changes  had  been 
less  intense,  inflammation  of  the  nerve  trunk  was  found  by 
Yirchow — inflammation  which  was  naturally  assumed  to  have 
been  communicated  to  the  optic  nerve  from  the  inflamed 
meninges,  and  to  have  descended  the  nerve  to  the  eye.  This 
condition  von  Graefe  designated  "  descending  neuritis,"  and 
gave  as  its  characteristics  a  slight  degree  of  change  in  the 
discs  and  a  tendency  to  invade  the  adjacent  retina.  On  the 
other  hand,  the  cases  of  tumour,  with  great  intra-ocular 
change,  haemorrhages,  &c.,  and  no  evidence  of  inflammation 
in  the  optic-nerve  trunks,  he  explained  by  the  theory  that 
they  were  due  to  the  effect  on  the  circulation  of  the  eye  of 
the  increased  intra-cranial  pressure,  which  he  assumed  to  be 
invariable  in  these  cases,  and  to  obstruct  the  return  of  blood 
from  the  eye  by  compressing  the  cavernous  sinus.  He 
suggested  further  that  this  mechanical  effect  was  greatly 
intensified  by  the  unyielding  character  of  the  sclerotic  ring, 
which  would  act,  he  assumed,  as  a  multiplier  of  the  mechani- 
cal obstruction.  In  accordance  with  this  view  he  appHed  to 
the  condition  of  disc  met  with  in  these  cases — considerable 

1  In  a  communication  to  the  Societe  de  Biologic  of  Paris  in  November, 
1859  ("Gazette  Hebdom.,"  1859),  and  more  fully  described  in  the  "Arch, 
f.  Ophth.,"  vii.  1860,  pt.  2,  p.  58. 

2  "  Arch.  f.  Ophth.,"  xii.  p.  100. 


CHANGES    IN    THE    OPTIC    NERVE NEURITIS.  79 

swelling  with  haemorrhage  and  vascular  distension  —  the 
term  u  staimngs-papille  "  (stauung,  a  damming  back),  in  dis- 
tinction from  the  "  descending  neuritis."  In  this  country, 
by  the  suggestion  of  Clifford  Allbutt,  the  term  "  choked 
disc "  has  come  into  use  as  a  synonym  for  "  stauungs- 
papille." 

It  was  soon  pointed  out  as  strange  that  an  actual 
inflammation  should  result  from  a  mechanical  congestion,  and 
as  still  more  strange  that  the  inflammation  thus  excited 
should  remain  limited  so  nearly  to  the  papilla.  But  graver 
difficulties  awaited  this  theory  of  the  "  stauungs-papille." 
It  was  found  that  the  ophthalmoscopic  signs  of  the  two 
forms  of  neuritis  could  not  always  be  relied  upon.  The  con- 
dition supposed  to  be  characteristic  of  descending  neuritis 
was  discovered,  in  some  cases,  to  be  but  the  first  stage  of  that 
supposed  to  indicate  mechanical  obstruction.  It  was  found, 
also,  that  when  the  character  of  one  of  the  two  forms  was 
clear  the  necropsy  might  show  the  case  to  be  really  one 
of  the  other  variety.  Cases  of  this  character  were  frankly 
published  by  von  Grraefe,  although  he  still  held  that  the 
distinctions  were,  in  the  majority  of  cases,  accurate,  and  the 
supposed  mechanism  of  the  "  stauungs-papille "  effective. 
This  theory,  however,  was  destroyed  in  its  substantive  form  in 
1869  by  the  demonstration  by  Sesemann1  that  the  communi- 
cation between  the  supra-orbital  and  the  facial  veins  was  so 
free  that  the  effect  of  pressure  on  the  cavernous  sinus  was  at 
once  relieved,  and  did  not  cause  more  than  a  very  transient 
fulness  of  the  retinal  veins,  and  that  even  obliteration  of  the 
cavernous  sinus  produced  no  intra-ocular  changes.  This 
has  since  been  well  corroborated,  as,  for  instance,  by  a  case 
recorded  by  Hutchinson,  in  which  no  distension  of  the  retinal 
veins  was  produced,  although  the  cavernous  sinus  was  com- 
pletely obliterated  by  the  pressure  of  an  aneurism.  It  has, 
indeed,  been  said  that  the  openings  from  the  orbital  into  the 
facial  vein  are  often  larger  than  the  communication  with  the 
cavernous  sinus. 

1  "  Reichert  u.  Du  Bois  Reymond's  Archiv,"  1869,  p.  154. 


80  MEDICAL   OPHTHALMOSCOPY. 

It  was  discovered  by  Schwalbe1  that  the  subvaginal  space 
around  the  optic  nerve  is,  at  the  optic  foramen,  continuous 
with,  and  can  be  injected  from,  the  subdural  space  around  the 
brain.2  This  gave  significance  to  some  earlier  observations  of 
Stellwag  von  Carion3  and  Manz4  that  the  sheath  of  the  nerve 
may  be  distended  in  optic  neuritis  from  tumour  and  menin- 
gitis. The  two  facts  suggested  to  Schmidt5  that  intra-cranial 
pressure  may  influence  the  intra-ocular  termination  of  the 
optic  nerve  by  this  mechanism,  since,  as  already  described, 
the  distension  of  the  sheath  is  greatest  just  behind  the  globe. 
The  theory  received  support  from  Manz,6  who  showed  how 
frequent  distension  of  the  sheath  is  in  optic  neuritis,  and 
believed  it  to  be  invariable  in  cases  of  increase  of  infra-cranial 
pressure  or  increase  of  subarachnoid  fluid.  He  urged  that 
the  simple  pressure  on  the  nerve  and  vessels  might  cause  the 
intra-ocular  changes,  and  endeavoured,  by  experiment  on 
animals,  to  demonstrate  this  effect  of  the  vaginal  distension. 
Injections  into  the  subdural  space  passed  into,  and  distended, 
the  sheath,  and  caused  fulness  of  the  retinal  veins,  and  in  some 
cases  transient  redness  and  swelling  of  the  papilla. 

Schmidt,  however,  found  that  a  coloured  liquid  injected 
into  the  sheath  passed  into  lymph  spaces  in  the  nerve  at 
the  lamina  cribrosa,  and  he  suggested  that  neuritis  is  pro- 
duced, not  by  the  simple  pressure  outside  the  nerve,  but  b}r 
the  influence,  perhaps  irritation,  of  the  liquid  passing  into 
these  lymph  spaces.  The  theories  of  Schmidt  and  Manz  have 
been  largely  accepted  in  Germany  as  affording  the  mos^ 
satisfactory  explanation  of  the  origin  of  optic  neuritis. 
Leber,7  while  adopting  the  view  that  the  distension  of  the 

1  „  Centralblatt  f.  Med.  Wiss.,"  1869,  p.  465.      "Arch.   f.   Mikroskop. 
Anat,"  Bd.  vi.  1870,  p.  1. 

2  It  has    been    stated    by    Parinaud    that  the   communication    is    with 
the  subarachnoid,    not   with    the   subdural    space   ("Ann.    d'Oculistique," 
vol.  Ixxxii.  1879,  p.  25). 

3  "Ophthalmologie,"  vol.  ii.  1856,  p.  612. 

4  "Zehender's  Monatsbl.,"  vol.  iii.  1865,  p.  281. 

5  Of   Marburg,    now   Schmidt-Rimpler.      "Arch.   f.    Ophth.,"    vol.  xv. 
1869,  p.  193. 

«  "Deutsch.  Arch.  f.  Klin.  Med.,"  vol.  ix.  1871,  p.  339. 

7  Discussion  at  the  International  Medical  Congress,  London,  1881. 


CHANGES    IN    THE    OPTIC    NERVE — NEURITIS.  81 

sheath  is  the  immediate  excitant  of  neuritis,  doubts  the  theory 
of  Manz,  that  the  fluid  acts  by  mechanical  pressure,  and 
rejects  the  effect  on  the  lymphatic  spaces  assumed  by  Schmidt, 
on  the  ground  that  his  own  and  other  investigations  have 
failed  to  confirm  the  asserted  communication  of  these  spaces 
with  the  sheath.  Leber  suggests  that  the  fluid  in  the  sheath 
excites  neuritis,  by  conveying  pathogenic  material  to  the  optic 
nerve  behind  the  eye.  Deutschmann1  has  recently  published 
experimental  evidence  in  favoiir  of  Leber's  view,  and  in 
opposition  to  the  theory  of  "choked  disc"  from  the  distension 
of  the  nerve-sheath. 

It  was  suggested  in  1863  by  Hughlings- Jackson,2  that 
intra-cranial  tumour  causes  optic  neuritis  by  its  irritating 
effect,  acting  as  a  "  foreign  body,"  and  this  view  was  sup- 
ported a  little  later  by  Brown-Sequard,  who  compared  the 
origin  of  neuritis  in  intra-cranial  tumour  to  the  production  of 
atrophy  of  the  optic  nerve  by  a  distant  source  of  irritation. 
It  was  more  precisely  formulated  by  Benedikt3  in  1868,  by 
ascribing  the  mechanism  to  the  vaso-motor  nerves,  and  it  is 
sometimes  termed  his  theory.4  This  view  assumes  that  the 
tumour  acts  as  a  source  of  irritation,  producing  a  reflex 
influence  through  the  vaso-motor  nerves  upon  the  optic  disc, 
and  thus  leading  to  its  inflammation.  It  has  been  rejected 
by  most  writers  on  the  grounds  stated  by  Leber,5 — that 
it  involves  a  mechanism  not  known  to  exist,  and  a  com- 
plex relation  of  the  optic  nerve  to  all  parts  of  the  brain 
difficult  to  conceive  ;  and  by  Clifford  Allbutt,  on  the  ground 
that  he  has  failed  to  find  around  tumours  the  signs  of 
irritation.  The  theory  is,  however,  still  held  by  Hughlings- 
Jackson  as  that  which  best  explains  the  phenomena  of 

1  "On  Optic  Neuritis,  especially  the  so-called  Choked  Disc,  audits  connec- 
tion with  Brain  Diseases."      Jena,  1887,  and  "Oph.  Rev.,"  vol.  vi.   1887, 
p.  107. 

2  "Ophth.  Hosp.  Rep.,"  vol.  iv. 

3  "  Allg.  Wien.  Med.  Zeit.,"  1868,  No.  3. 

4  Schneller,  in  1860,  put  forward  a  similar  theory  when  he  suggested  that 
some  retinal  changes  in  intra-cranial  disease  might  be  due  to  a  "primary 
affection  of  the  centres  of  those  nerves  which  regulate  the  course  of  the 
blood  in  the  ocular  vessels." — "Arch.  f.  Ophth.,"  Bd.  vii.  1860,  I.  p.  71. 

5  In  "Graefe  u.  Saemisch's  Handbuch,"  Bd.  v. 

O 


82  MEDICAL   OPHTHALMOSCOPY. 

neuritis ;  he  has  always  urged  that  the  occurrence  of  optic 
neuritis  is  not  related  to  increased  intra-cranial  pressure. 
Gralezowski  helieves  that  neuritis  is  always  descending, 
and  first  maintained,  contrary  to  previous  observers,  that 
the  intra-ocular  change  is  in  all  cases  the  visible  mani- 
festation of  an  inflammation  propagated  by  continuity  from 
the  brain.  Edmunds  and  Lawford  are  of  opinion  that  optic 
neuritis,  when  due  to  an  intra-cranial  cause,  is  secondary  to 
basal  meningitis,  and  that  the  inflammation  reaches  the 
substance  of  the  nerve-trunk  through  its  sheath.1  Lastly, 
Parinaud2  asserts  that  neuritis  is  invariably  the  effect  of  dis- 
tension of  the  ventricles  of  the  brain,  which  causes  general 
cerebral  oedema,  and  of  this  both  the  distension  of  the 
sheath  and  the  papillitis  are  equally  part. 

The  clinical  and  pathological  evidence  bearing  on  these 
views  may  be  briefly  reviewed. 

The  first  point  to  be  borne  in  mind  is  that  optic  neuritis 
limited  to,  or  at  least  most  intense  in,  the  optic  papilla, 
may  occur  without  any  obvious  intra-cranial  disease.  The 
intense  neuritis  shown  in  PI.  VIII.  1  was  apparently  a 
primary  papillitis,  involving  the  retina  only  secondarily, 
due  to  anaemia.  This  patient  had  no  symptom  of  cerebral 
disease,  save  some  headache,  during  two  years  she  re- 
mained under  observation.  The  neuritis  reached  its  height 
in  about  a  fortnight  from  its  commencement,  a  rapidity 
which  is  seen  in  neuritis  from  intra-cranial  disease  only  in  the 
most  acute  cerebral  affections ;  this  circumstance,  with  the 
absence  of  cerebral  symptoms,  excludes  the  supposition 
that  there  existed  intra-cranial  disease.  Limited  papillitis 
is  now  known  to  occur  in  simple  anaemia.  From  these 
considerations  it  seems  to  follow  that  the  intra-ocular  ter- 
mination of  the  optic  nerve  is  a  structure,  for  some  reason 
which  we  do  not  know,  peculiarly  prone  to  suffer  inflamma- 
tion. The  common  localization  of  the  inflammation  to  the 
papilla  points  also  to  the  same  fact. 

1  ''Trans.   Ophth.  Soc..,"  vol.  i.  p.  Ill  ;  vol.  Hi.  p.  138  ;    vol.   iv.  p.  172  ; 
vol.  v.  p.  184  ;  vol.  vii.  p.  208. 

2  See  "Graefe  u.  Saemisch's  Handbuch,"  Bd.  v. ;  "Ann.  d'Ocul.,"  t.  Ixxxii. 
p.  5. 


CHANGES    IN    THE    OPTIC   NERVE — NEURITIS.  83 

The  facts  of  medical  ophthalmoscopy  certainly  make  it 
difficult  to  connect  papillitis  with  increase  of  intra-cranial 
pressure.  If  we  consider  the  cases  in  which  intra-cranial 
pressure  is  raised  to  the  highest  point  it  ever  reaches — chronic 
hydrocephalus — we  find  optic  neuritis  the  rare  exception, 
and,  when  it  occurs,  never  intense.  The  difficulty  cannot 
be  met  by  attributing  it  to  the  slowness  with  which  the 
pressure  is  raised,  because  the  growth  of  many  tumours, 
which  cause  intense  optic  neuritis,  is  equally  slow. 

On  the  other  hand,  as  I  have  many  times  seen,  in  cases 
of  tumour  with  neuritis  there  may  be  no  sign  of  increased 
intra-cranial  pressure  during  life  or  after  death.  "  In  these 
cases  of  vast  tumours,  the  optic  neuritis  does  not  differ  from 
that  caused  by  small  tumours  at  the  vertex  of  the  brain, 
which  cannot  exercise  pressure  of  any  consequence  at  the 
base."  "  The  neuritis  runs  through  its  stages,  and  the  swelling 
of  the  discs  subsides,  although  the  intra-cranial  pressure  goes 
on  increasing." l  There  may  also  be  signs  of  increased  pressure 
in  tumour  without  optic  neuritis.  But,  while  pressure  upon 
the  cavernous  sinus  cannot  be  regarded  as  the  cause  of  neu- 
ritis, its  influence  on  the  retinal  vessels  cannot  be  altogether 
excluded.  Experiments  show  that  a  quickly  induced  increase 
of  pressure  within  the  skull  causes  a  transient  distension 
of  the  retinal  and  papillary  vessels.  In  tubercular  menin- 
gitis (q.v.)  Grarlick's  careful  observations2  have  shown  that, 
while  papillitis  is  not,  fulness  of  veins  is  related  to  an 
increased  intra-cranial  pressure. 

In  the  course  of  a  descending  neuritis  the  distension  of 
veins  may  be  very  great,  as  I  have  several  times  observed 
both  during  life  and  after  death  (see  Figs.  6  and  24).  In 
tumour  the  veins  at  first,  and  often  throughout  (when  the 
neuritis  does  not  reach  a  considerable  degree  of  intensity), 
are  little  above  the  normal  size,  and  present  no  tortuosities 
except  those  which  are  given  them  by  the  prominence  of 
the  papilla.  The  great  distension  of  veins  and  narrowing  of 

1  Hughlings- Jackson  :    Lecture   on    Optic    Neuritis,    "  Med.    Times    and 
Gaz.,"  1871,  vol.  ii.  p.  581. 

2  "Med.-Chir.  Trans.,"  vol.  Ixii.  1879,  p.  441. 


84  MEDICAL    OPHTHALMOSCOPE. 

arteries  occur  when  the  inflammation  has  reached  a  certain 
degree  of  intensity.  This  points  to  the  neuritic  process  in 
the  papilla  as  causing  the  strangulation  by  pressure  on 
the  vessels.  This  view  is  entirely  borne  out  by  patho- 
logical investigation.  I  have  never  been  able  to  dis- 
cover any  evidence  of  constriction  of  the  vessels  in  the 
sclerotic  ring  or  behind  it.  Their  calibre  here  is  always 
uniform  (see  Figs.  16,  19,  21,  and  44).  This  state- 
ment is  based  on  a  very  careful  search  for  any  evidence  of 
such  compression  in  a  number  of  cases  of  papillitis  from 
various  intra-cranial  diseases.  In  one  case  only  was  there  an 
appearance  of  narrowing,  and  in  this,  from  the  unaltered 
course  of  an  adjacent  vessel,  it  was  evidently  due  to  a  slight 
alteration  in  the  position  of  the  vessel  at  the  spot,  in 
consequence  of  which  the  sections  ceased  to  pass  through  its 
widest  part.  It  is  always  in  front  of  the  sclerotic,  in  the 
substance  of  the  swollen  papilla,  that  the  vessels  present 
conspicuous  constriction  —  are  pressed  upon,  and  have 
their  walls  thickened  by  new  tissue  (Figs.  10,  20,  22, 
23,  &c.).  Further,  the  most  intense  signs  of  "  strangula- 
tion "  may  be  seen  in  cases  in  which,  as  in  that  of  neuro- 
retinitis  due  to  chlorosis  (Plate  VIII.  1),  there  is  reason  to 
Relieve  there  is  no  intra-cranial  disease ;  and  in  the  case  of 
•chronic  cerebritis,  quoted  at  p.  89,  in  which  there  was  no 
intra-cranial  condition  which  could  cause  any  mechanical 
effect,  the  intra-ocular  signs  of  constriction  and  mechanical 
congestion  were  very  marked. 

Distension  of  the  optic  sheath  is  certainly  very  frequent 
in  cases  of  optic  neuritis.  It  is  not,  however,  as  has  been 
alleged,  invariable,  either  in  cases  of  cerebral  tumour  with 
optic  neuritis,  or  in  conditions  of  increased  intra-cranial 
pressure.  It  may  be  absent  in  tumour  of  the  brain  with 
characteristic  neuritis;  for  instance,  in  one  case  a  large  glioma 
of  the  right  frontal  lobe,  with  haemorrhage  into  it,  was 
attended  by  optic  neuritis,  but  with  no  distension  of  the 
sheath.  This  may  also  be  absent  in  tumour  with  internal 
effusion  ;  great  distension  of  the  lateral  and  third  ventricles 
was  caused  in  another  case  by  a  tumour  near  the  corpora 


CHANGES    IN    THE    OPTIC    NERVE NEURITIS.  85 

quadrigemina, — there  was  optic  neuritis  but  no  distension  of 
the  sheaths.  A  case  of  tumour  of  the  cerebellum  with  optic 
neuritis  and  no  distension  of  the  sheaths  has  been  recorded 
by  Nettleship.1  In  another  case  of  old  neuritis,  due  to  a 
tumour  occupying  the  whole  of  the  third  ventricle  and  inter- 
peduncular  space,  extending  in  front  of  the  optic  commissure 
and  causing  enormous  distension  of  the  lateral  ventricles,  the 
optic  sheaths  carefully  examined  in  situ  were  quite  empty. 
But  they  were  loose,  and  had  evidently  been  much  distended. 
This  case  suggests  that  pressure  at  the  base  of  the  brain  may 
even  be  incompatible  with  continued  distension  of  the  sheath. 
Distension  was  absent  in  a  case  of  neuritis  from  cerebral 
abscess  recorded  by  Carrier,2  and  in  a  case  of  double  neuro- 
retinitis,  apparently  secondary  to  cerebral  haemorrhage, 
which  has  been  recorded  by  Gremuseus.3  In  tubercular 
meningitis,  again,  the  condition  to  which  the  distension 
of  the  sheath  appears  to  be  related  is  not  distension  of 
the  ventricles,  or  increased  intra-cranial  pressure,  but  in- 
crease of  the  subarachnoid  fluid,  and  it  bears  in  this  disease 
certainly  no  relation  to  the  occurrence  of  neuritis.  Of 
six  cases  with  changes  in  the  papilla,  in  which  the  state  of 
the  optic  sheaths  was  carefully  noted  by  Dr.  Grarlick,  in  four, 
in  which  excess  of  subarachnoid  fluid  was  absent,  the  sheath 
was  normal,  although  in  several  there  was  great  distension  of 
the  ventricles,  while  in  the  remaining  two  cases,  in  which 
there  was  an  excess  of  subarachnoid  fluid,  there  was  also 
dropsy  of  the  optic  sheath.  A  case  of  neuritis  in  tubercular 
meningitis,  without  distension  of  the  sheath,  has  also  been 
described  by  Edmunds.4  It  has  been  suggested  that 
the  fluid  may  be  formed  within  the  sheath  itself,  being 
prevented  from  passing  backwards  to  the  cranium  by  the 
intra-cranial  pressure.  If  the  sheath  of  the  optic  nerve 
is  the  chief  lymph-channel  by  which  fluid  is  conveyed 
away  from  the  eye,  its  distension  in  optic  neuritis,  by 

1  "Path.  Trans.,"  1880,  p.  252. 

2  "  Philadelphia  Med.  Times,"  Jan.  29,  1880. 

3  "Klin.  Monatsbl.  f.  Augenheilk.,"  1880,  p.  380, 

4  "Trans.  Ophth.  Soc.,"  vol.  i.  1881,  p.  112, 


86  MEDICAL    OPHTHALMOSCOPY. 

fluid  escaping  from  the  papilla,  is  intelligible.  But  this 
fact  is,  at  least,  uncertain  (see  above,  p.  81).  Moreover,  the 
case  of  tumour  in  the  third  ventricle,  referred  to  in  the  previous 
page,  seems  opposed  to  this  theory.  The  optic  sheaths  had 
been  greatly  distended,  but  they  had  become  empty,  apparently 
in  consequence  of  the  pressure  on  the  front  of  the  base,  by 
the  large  tumour  in  the  anterior  part  of  the  third  ventricle, 
cutting  off  the  communication  with  the  subarachnoid  space. 
If  the  fluid  were  derived  from  the  eye,  this  influence  should 
have  increased  the  distension  of  the  sheaths,  instead  of 
causing  them  to  become  empty.  There  is  thus  strong 
reason  to  believe  that  the  fluid  in  the  sheath  of  the  optic 
nerve  passes  into  it  from  the  subarachnoid  space.  The 
absence  of  obvious  excess  of  the  subarachnoid  fluid  in  some 
cases,  as  in  an  instance  mentioned  by  Edmunds,1  is  not  of 
much  weight  as  evidence  against  this  conclusion,  because  a 
general  increase  of  intra-cranial  pressure  (e.g.,  by  ventricular 
effusion)  which  would  assist  in  forcing  the  fluid  into  the 
sheaths,  would  at  the  same  time  tend  to  remove  it  from  the 
base  of  the  brain  where  its  amount  is  estimated. 

Of  the  frequent  association  of  dropsy  of  the  sheath  and 
optic  neuritis  there  can  be  no  doubt,  but  of  the  relation  of 
one  to  the  other,  little  evidence  has  yet  been  adduced.  Manz 
admits  that  there  are  probably  various  kinds  of  effusion  into 
the  sheath,  and  that  all  may  not  lead  to  neuritis.  Parinaud 
has  asserted  that  it  is  common  in  cases  of  pulmonary  obstruc- 
tion, as  in  croup.  It  is  certain,  too,  that  distension  of  the 
optic  nerve-sheath  may  occur  even  in  meningitis  without 
causing  neuritis,  as  in  a  case  recorded  by  Broadbent.  But 
such  cases  prove  little,  because  the  duration  of  the  dropsy 
may  not  have  been  sufficient  for  the  inflammatory  changes  to 
arise.  The  occasional  occurrence  of  papillitis  without  it — a 
fact  which  is  well  established — shows  that  it  is  not  the 
invariable,  and  suggests  that  it  is  not  the  chief,  mechanism 
by  which  papillitis  is  produced.  But,  it  is  probable  that, 
although  not  the  chief  cause,  it  may  still  exercise  an 
important  influence  on  the  process. 

1  "Trans.  Ophth.  Soc.,"  vol.  i.  1881,  p.  112. 


CHANGES    IN    THE    OPTIC    NERVE NEURITIS. 


87 


In  examining  the  trunk  of  the  optic  nerve  behind  the  eye, 
in  cases  of  papillitis  from  cerebral  tumour,  I  have  found  the 
optic  nerve  to  present  traces  of  inflammatory  change,  increase 
of  nuclei  and  connective  tissue,  much  more  frequently  than 


FIG.  44. 


FIG.  45. 


FIG.  46. 


SECTIONS  FROM  A  CASE  OF  OPTIC  NEURITIS 
Due  to  a  tumour  in  the  frontal  lobes. 

FIG.  44. — SECTION  THROUGH  THE  Disc.  Swelling  of  the  papilla,  displacement 
of  the  retina  outwards.  Aggregation  of  leucocytes  along  the  course  of  the 
vessels,  thus  indicating  their  position.  No  sign  of  compression  of  vein 
when  passing  through  the  sclerotic  ring.  No  distension  of  the  sheath  of 
the  nerve  ( x  15). 

FIG.  45. — PART   OF  A  TRANSVERSE  SECTION  THROUGH  THE  OPTIC  NERVE, 

MIDWAY   BETWEEN   THE  GLOBE  AND   THE   OPTIC   FORAMEN.       Increase  of 

leucocytes  and  some  degeneration  in  the  nerve  fibres  (  x  100). 

FIG.  46. — TRANSVERSE  SECTION  JUST  IN  FRONT  OF  THE  COMMISSURE.  The 
bundles  of  nerve  fibres  are  separated  by  much  newly  formed  fibrous  tissue, 
which  is  encroaching  on  the  fasciculi  of  the  nerve.  The  nerve  fibres  are 
degenerated,  and  many  leucocytes  are  scattered  among  them  (x  100). 


88  MEDICAL    OPHTHALMOSCOPY. 

has  been  stated  by  other  observers.  The  changes  were 
especially  marked  towards  the  periphery  of  the  trunk  and  in 
the  pial- sheath.  In  not  one  case  examined  could  the  nerves 
be  said  to  be  in  a  perfectly  normal  state.  The  significance 
of  the  changes  is  open  to  question.  They  may  possibly  be 
regarded,  in  some  cases,  as  indications  of  an  ascending 
neuritis.  But  in  some  they  were  most  intense  in  the  neigh- 
bourhood of  the  optic  commissure  (compare  Figs.  45  and  46), 
and  there  was  evidence  that  a  neuritis  had  taken  place  there 
by  extension  from  the  meninges.  In  several  cases  in  which 
this  was  most  distinct,  the  change  in  the  optic  nerve,  mid- way 
between  the  commissure  and  the  eye,  was  so  slight  that  it 
might  almost  have  been  passed  as  normal  (Fig.  45. 
See  also  Figs.  26  and  29).  The  extension  to  the 
nerve  was  very  distinct  in  two  cases  of  intra-cranial 
tumour  under  my  care.  In  one  there  was  distinct,  although 
very  slight,  evidence  of  meningitis  beneath  the  orbital 
lobules,  which  had  evidently,  by  the  naked-eye  and  micro- 
scopic appearances,  extended  to  the  nerves.  In  the  other 
case  (Fig.  44)  the  papillitis  was  considerable,  and  such  as  is 
most  common  in  cerebral  tumour.  The  changes  in  the  optic 
nerves  in  the  middle  of  their  course  were  slight  but  distinct 


,-'-"•*>  • 


FIG.  47.  FIG.  48. 

SECTIONS  THROUGH  THE  OPTIC  NERA-E  IN  A  CASE  OF  CHRONIC 

CEREBRITIS  ( x  100). 
FIG.  47. — Just  behind   the   globe,    containing  many  leucocytes  within  the 

fasciculi. 

FIG.  48. — Just  in  front  of  the  commissure.  There  is  more  infiltration 
with  leucocytes,  and  the  connective  tissue  septa  are  more  thickened 
and  irregular. 


CHANGES    IN    THE    OPTIC    NERVE NEURITIS.     -  5 

(Fig.  45).  In  front  of  the  optic  commissure  (Fig.  46) 
the  changes  from  old  inflammation  were  intense.  No  sign 
of  adjacent  meningitis  was  noted  at  the  post-mortem 
examination,  but  there  were  old  adhesions  over  the  tumour 
on  the  upper  part  of  the  frontal  lobe.  In  this  case  it  seems 
probable  that  descending  neuritis  had  taken  place,  and 
that  the  link  between  the  intense  neuritis  behind,  and  the 
intense  papillitis  in  front,  was  the  slight  change  in  the  trunk 
of  the  nerve.  Hence  it  seems  that  a  very  slight  amount  of 
descending  change  may  lead,  in  cerebral  tumour,  to  an 
intense  papillitis.  With  this  case  may  be  compared  another, 
of  a  man  who  was  in  the  London  Hospital  under  the  care 
of  Dr.  Hughlings-Jackson,  in  which  the  appearance  of  the 
papilla  was  declared  by  an  authority  so  decisive  as  that  of 
Mr.  Gouper  to  be  that  of  a  "  choked  disc."  No  tumour, 
meningitis,  or  mechanism  for  "  choking "  was,  however, 
discovered  within  the  cranium.  But  the  trunk  of  the  nerve 
presented  changes  very  similar  to  those  in  the  case  just 
mentioned,  not,  however,  more  intense  at  its  posterior 
portion.  Similar  changes  were  found  throughout  the  brain 
by  Dr.  Sutton,  and  it  can  hardly  be  doubted,  taking  the 
symptoms  and  anatomical  changes  together,  that  a  condition, 
which  must  be  regarded  as  "  chronic  irritation  or  inflamma- 
tion "  affecting  the  brain,  had  passed  down  the  optic  nerves 
and  appeared  as  an  intense  papillitis,  with  signs  of  strangu- 
lation, due  to  the  compression  of  the  vessels  within  the 
papilla.  A  similar  case  has  been  recorded  by  Stephen 
Mackenzie.1 

It  seems  from  these  facts  that  (1)  a  descending  neuritis 
cannot  be  excluded  from  an  examination  of  a  small  portion 
of  the  trunk  of  the  nerve,  and  (2)  that  a  change  in  the  nerve 
revealing  itself  as  a  very  slight  deviation  from  the  normal, 
may  serve  to  convey  a  condition  of  irritation  to  the  eye 
sufficient  to  light  up  considerable  papillitis. 

The  frequency  with  which  evidence  of  descending  neuritis 
may  be  traced  is  confirmed  by  the  observations  of  S.Mackenzie,2 

1  "  Brain,"  July,  1879,  p.  269. 

2  Loc.  cit.  and  "Trans.  Ophth.  Soc.,"  vol.  i.  p.  94. 


DO  MEDICAL   OPHTHALMOSCOPY. 

Brailey,1  Edmunds  and  Lawford,2  Poncet,3  and  others. 
Mackenzie  has  also  pointed  out  that  on  no  other  theory 
than  that  of  an  inflammation  travelling  down  the  nerve 
tissue  can  we  explain  a  unilateral  neuritis  on  the  side 
opposite  to  a  cerebral  tumour. 

It  has  been  maintained  by  Kuhnt4  that  the  descent  of 
inflammation  from  the  brain  to  the  eye  is  by  the  perivascular 
sheaths  of  the  vessels,  which  are,  he  states,  continuous  with 
the  pia  mater  of  the  brain,  and  Gayet5  would  ascribe  a  share 
also  to  the  sheaths  of  the  posterior  ciliary  vessels.  The 
evidence  of  inflammation  away  from  the  vessels  prevents 
us,  however,  regarding  them  as  the  exclusive  agents, 
but  pathological  evidence  of  their  participation  in  the 
transmission  of  the  inflammation  has  been  also  brought 
forward  by  Edmunds  and  Brailey.6 

It  has  been  pointed  out  that  the  sheaths  of  the  nerve,  inner 
and  outer,  often  present  considerable  changes,  which  make  it 
probable  that  the  inflammation  passes  along  them  to  the  eye. 
That  it  may  do  so  independently  of  distension  of  the  sheath 
is  shown  by  two  cases  of  optic  neuritis  and  meningitis  due 
to  fracture  of  the  skull,  recently  recorded  by  Edmunds,7 
in  which  the  space  between  the  sheaths  of  the  nerve  was 
occupied  by  "  a  dense  mass  of  inflammatory  products." 

These  facts  suggest  the  following  conclusions  regarding 
.the  production  of  papillitis  in  intra-cranial  disease: — 

That  in  cases  of  cerebral  tumour  evidence  of  descending 
inflammation  may  be  traced  in  sheath  or  nerve,  much  more 
commonly  than  current  statements  suggest,  while  in  cases  of 
meningitis  the  evidence  of  such  descending  inflammation  is 
almost  invariable. 

That  the  resulting  papillitis  may  be,  and  remain,  slight, 

1  "Trans.  Ophth.  Soc.,"  vol.  i.  p.  111. 

2  Ibid.,  p.  112,  and  loc.  cit.  at  p.  82. 

3  Disc,  at  the  International  Med.  Congress,  1881. 

4  In  a  communication  to  the  International  Medical  Congress  at  Amsterdam 
("Ann.  d'Oculist.,"  vol.  Ixxxii.  1879,  p.  180).  6  Ibid.,  p.  181. 

6  "Ophth.  Hosp.  Rep.,"  vol.  x.  p.  138. 

7  "St.  Thos.   Hosp.   Rep.,"  vol.  xi.   1881.  p.  71;    "Trans.   Ophth.  Soc.," 
vol.  iii.  p.  140. 


CHANGES    IN    THE    OPTIC    NERVE NEURITIS.  91 

or  may  become  intense  and  present  the  appearances  of 
mechanical  congestion.  The  causes  of  this  difference  we 
do  not  yet  know. 

That  such  mechanical  congestion  does  not,  as  a  rule,  result 
from  compression  of  the  vessels  in  or  just  behind  the  sclerotic 
ring,  but  always,  when  intense,  from  compression  by  inflam- 
matory products  in  the  substance  of  the  papilla.  It  must  not 
be  forgotten  that  an  increase  in  the  size  of  vessels  may  be  of 
reflex  vaso-motor  origin  as  in  all  inflamed  parts. 

That  while  slow  increase  of  intra-cranial  pressure  has  no 
effect  on  the  retinal  vessels,  a  sudden  increase  hinders  the 
escape  of  blood  from  the  eye  for  a  time,  and  may  intensify  a 
papillitis  originating  in  another  way. 

That  distension  of  the  sheath  of  the  nerve  alone  is  probably 
insufficient  to  cause  papillitis  by  its  mechanical  effect,  but  may 
perhaps  intensify  the  process  otherwise  set  up,  especially  if 
the  fluid  possesses  an  irritative  quality,  and  if  (as  Schmidt- 
Bimpler  asserts  and  Leber  denies)  it  can  find  its  way  into 
the  lymphatic  spaces  of  the  optic  disc.1 

There  being  thus  little  evidence  that  a  mechanical  impe- 
diment to  the  return  of  blood  from  the  eye — induced  either 
by  intra-cranial  pressure,  by  distension  of  the  optic  sheath, 
•or  by  the  pressure  of  the  sclerotic  ring — ever  plays  any 
considerable  part  in  the  production  of  optic  neuritis,  the  use 
of  the  term  "  choked  disc  "  or  "  stauungs-papille,"  as  indi- 
cative of  a  supposed  mechanism,  is  to  be  deprecated  in  our 
present  state  of  knowledge.  The  occurrence  of  a  process  of 
strangulation  is  not  denied ;  it  is  often  conspicuous  enough, 
but  it  is  produced  in  the  inflamed  papilla  and  not  behind 
the  eye,  and  occurs  in  all  cases  of  a  certain  intensity. 

In  this  outline  of  the  facts  regarding  the  origin  of  optic 
neuritis,  the  hypothesis  that  the  mechanism  is  a  reflex  vaso- 
motor  influence  has  been  necessarily  unnoticed,  because  the 
known  facts  have  no  bearing  upon  it  and  give  it  no  support. 
It  presupposes  a  special  reflex  relation  not  known  to  exist 

1  The  latest  theory  of  Leber,  viz.,  that  papillitis  is  an  extension  of  inflam- 
mation from  the  periphery  of  the  nerve  at  the  anterior  extremity  of  the  sheath, 
is  not  supported  by  any  anatomical  evidence. 


92  MEDICAL    OPHTHALMOSCOPY. 

and  a  mechanism  for  the  production  of  inflammation   the 
efficiency  of  which  is  equally  unknown. l 

VARIETIES. — The  chief  varieties  which  have  been  usually 
insisted  on  are  those  distinguished  by  v.  Graefe  as  "  descend- 
ing neuritis  "  and  the  "  choked  disc."  The  facts  already 
mentioned  make  it  more  than  doubtful  whether  the  patho- 
logical basis  of  the  distinction  is  correct,  and  it  is  generally 
admitted  that  the  supposed  distinctions  cannot  be  relied  upon. 
The  aspect  of  the  disc  varies  very  much  in  the  same  case 
at  different  times ;  at  one  time  the  characters  may  be  those 
supposed  to  be  indicative  of  a  descending  neuritis,  and  at 
another  time  those  ascribed  to  the  "  choked  disc."  But  the 
appearance  in  different  cases  also  frequently  continues  dif- 
ferent throughout  their  whole  course.  These  characters  are 
so  various,  and  the  intermediate  forms  are  so  numerous,  that 
it  is  exceedingly  difficult  to  separate  any  varieties  as  special 
"forms."  Some  cases  certainly  present  throughout  cha- 
racters which  are  regarded  as  those  of  descending  neuritis — 
especially  slightness  of  swelling,  a  tendency  for  the  changes 
to  be  most  intense  in  the  peripheral  part  of  the  papilla, 
leaving  the  centre  little  affected,  absence  of  haemorrhages, 
the  presence  of  white  spots,  isolated  or  about  the  vessels,  and 
a  striation  depending  rather  on  conspicuousness  of  nerve 
fibres  than  on  vaseularity.  These  changes  are  seen,  for 
instance,  in  PI.  III.  3  and  5,  and  also  of  a  wider  extent  and 
greater  intensity  in  PL  VI.  2.  On  the  other  hand,  great 
swelling,  with  vaseularity  and  distended  veins,  such  as  is 
seen  in  PI.  I.  6,  III.  4,  and  still  more  in  PL  VI.  L,  charac- 
terizes other  forms.  But  in  the  case  whose  disc  is  shown 
in  Fig.  16,  descending  neuritis  presented  the  characters  of 

1  A  fuller  consideration  of  the  theory,  and  the  arguments  against  it,  will 
be  found  in  some  remarks  I  made  in  the  discussion  on  optic  neuritis  at  the 
Ophthalmological  Society,  March  10,  1881  ("Transactions,"  vol.  i.  p.  105). 
Similar  arguments  were  brought  forward  by  Leber  at  the  discussion  at  the 
International  Congress.  The  reflex  theory  has  been  revived  by  Loring  ("New 
York  Med.  Journ.,"  June,  1882)  in  special  connection  with  the  fifth  nerve, 
but  still  as  a  pure  theory,  which,  while  unsupported  by  facts  (and  even 
opposed  by  them),  clearly  merits  detailed  discussion. 


CHANGES    IN    THE    OPTIC    NERVE NEURITIS.  93 

the  choked  disc,  while  the  changes  in  PL  V.  1  and  2,  3  and  4, 
slight  as  they  are,  were  in  each  case  associated  with  the 
symptoms  of  intra-cranial  tumour. 

Until  we  know  more  of  the  relation  between  pathological 
process  and  ophthalmoscopic  appearance,  it  seems  far  better 
to  found  varieties  purely  on  clinical  characters.  Of  varieties 
so  founded  the  following  have  seemed  to  me  the  most 
marked. 

1.  Slight  Papillitis,  including  the  condition  described  above 
as  congestion  with  oedema,  in  which  the  changes  are  so  slight 
as  to  dim,  but  not  obscure,  the  edge  of  the  disc  on  indirect 
examination,    although  it    may  be    invisible,  wholly   or   in 
part,  to    direct  examination   (PI.  I.  3,  4,  III.  3,  5,  V.   1, 
2,  3,  4. 

2.  Moderate  Papillitis. — Obscuration  of  the  edge  of  the  disc, 
or  of  the  affected  portion,  complete,  even  to  indirect  examina- 
tion ;   swelling  moderate,  commonly  reddish ;  veins  natural 
or  large ;  sometimes  white  tissue  about  the  vessels,  close  to 
them  or  extending  for  some  distance  on  the  disc  (PI.  I.  5,  6, 
III.  4,  IV.  1,  3,  V.  5,  6,  VI.  2). 

3.  Intense  Papillitis. — Great  swelling  ;  veins  at  first  large 
and  arteries  small ;  many  haemorrhages  ;  retina  often  involved 
by  direct  damage  or  by  haemorrhages.     Always  succeeds  a 
slighter  stage  in  which  the  evidence  of  strangulation  may  be 
at  first  little  marked  (PL  VI.  1,  VIII.  1). 

The  forms  in  which  the  changes  involve  the  adjacent 
retina  are  often  termed  "  neuro-retinitis  circumscripta  ;  "  and 
such  widespread  change  as  is  presented  in  PL  VIII.  1, 
although  originating  in  the  papilla,  merits  such  a  designa- 
tion. But  in  most  cases,  even  in  such  as  PL  VI.  1,  the 
retina  is  only  affected  adjacent  to  the  papilla,  or  elsewhere 
is  merely  the  seat  of  extravasations ;  and  since  there  is  no 
general  inflammation  of  the  retina,  the  term  "  retinitis " 
seems  unnecessary. 

Retro-ocular  Neuritis. — The  change  known  as  such — an 
interstitial  inflammation  of  the  nerve — is  a  mixed  condition  of 
inflammation  and  atrophy,  revealed  in  the  disc,  if  revealed  at 
all,  by  the  signs  of  simple  congestion,  rarely  those  of  slight 


94  MEDICAL   OPHTHALMOSCOPY. 

papillitis,  and  soon  passing  on  to  atrophy  with  narrowed 
vessels.  Little  is  known  of  the  exact  anatomical  changes  in 
this  form,  except  in  the  variety  which  has  been  termed  axial 
neuritis  (Forster),  in  which  chronic  inflammation  occupies  the 
axis  of  the  "nerve,  and  causes  a  central  scotoma.  It  will  he 
described  further  in  the  section  on  "  Atrophy." 

Retro-ocular  Perineuritis  is  a  condition  of  chronic  inflam- 
mation of  the  sheath  of  the  nerve  leading  to  thickening  of  its 
tissues,  and  purulent  infiltration  among  the  trabeculae.  The 
nerve  may  suffer  from  compression,  or  from  a  state  of  inter- 
stitial neuritis  which  may  spread  to  it  from  the  sheath.  It 
has  been  found  in  periostitis  of  the  orbit  (Homer),  and  in 
thickening  of  the  cranial  bones  constricting  the  optic  nerve 
(Michel).  It  causes  papillitis  in  some,  perhaps  in  all  cases,. 
but  this  does  not  necessarily  assume  the  appearance  described 
on  p.  51  as  "  perineuritis." 

DIAGNOSIS. — The  diagnosis  of  optic  neuritis  is  often  easy,, 
but  sometimes  presents  great  difficulty.  Of  all  its  signs  that 
which  first  attracts  attention  as  the  most  conspicuous  feature — 
the  increased  redness — is  of  least  value,  except  in  conjunction 
with  other  characters.  As  already  more  than  once  stated, 
the  redness  of  a  disc  free  from  neuritis  may  nearly  equal  that 
of  the  adjacent  choroid.  The  signs  which  are  of  greatest 
diagnostic  value  are  (1)  obscuration  of  the  edge  of  the  disc 
and  (2)  swelling.  These,  in  conjunction  with  increased 
redness,  or  change  of  colour  to  a  tint  not  normally  seen 
(such  as  the  peculiar  lilac-grey  so  often  presented),  constitute 
the  characteristic  symptoms.  The  obscuration  of  the  edge 
is  especially  significant.  It  indicates  undue  opacity  of  the 
tissue  (layer  of  optic  nerve  fibres)  in  front  of  the  edge.  Most 
of  the  nerve  fibres  pass  along  the  course  of  the  great  vessels, 
above  and  below  the  disc,  and  they  often  normally  obscure 
the  edge  of  the  disc  slightly  in  these  situations.  Sometimes 
they  are  densely  packed,  also,  on  the  nasal  side,  especially 
when  the  central  cup  is  very  large,  and  a  slight  obscuration 
is  produced  there  also ;  but  in  these  cases,  as  a  rule,  the  large 
size  of  the  physiological  cup  indicates  the  close  arrangement 


CHANGES    IN    THE    OPTIC    NERVE NEURITIS.  95 

of  the  fibres,  the  obscuration  is  slight  and  occurs  in  the  normal 
situations,  and  the  edge  of  the  disc  is  elsewhere  quite  sharp. 
In  these  cases  another  character  may  occasionally  be  observed 
in  a  slight  degree,  which,  in  more  intense  form,  is  conspicuous 
in  neuritis — the  radiating  striation  at  the  edges  of  the  disc. 
Normally  this  is  seen  where  the  nerve  fibres  are  most  closely 
aggregated,  especially  above  and  below ;  in  morbid  states  it 
is  to  be  observed  all  round  the  disc,  although  most  intense 
where  the  nerve  fibres  are  grouped,  and  it  is  then  due  not 
merely  to  pale  lines  (from  swollen  fibres  with  increased 
opacity),  but  in  part,  also,  to  red  lines,  fine  vessels  lying 
between  the  fibres. 

The  second  indication  of  neuritis  is  the  existence  of  distinct 
swelling.  The  prominence  of  one  object  in  the  fundus  above 
the  level  of  an  adjacent  object — e.  g.,  of  a  vessel  on  the  edge  of 
the  physiological  cup  above  a  vessel  at  its  bottom — is  appre- 
ciated in  the  direct  method  of  examination  by  moving  the 
head  of  the  observer  from  side  to  side,  or  up  and  down,  as  far 
as  possible  without  losing  sight  of  the  objects.  Their  rela- 
tive position  undergoes  an  appreciable  alteration  proportioned 
to  the  difference  in  level,  and  is  easily  recognized.  By  the 
indirect  method  of  examination  the  same  result  may  be 
obtained  by  a  lateral  or  vertical  movement  of  the  lens,  which 
produces  the  same  effect  as  a  corresponding  movement  of  the 
observer's  head  (the  "  parallactic  test"  of  Liebreich).  "With 
the  binocular  ophthalmoscope  these  measures  are  unnecessary, 
the  difference  of  level  being  apparent  just  as  with  the  stereo- 
scope. When  the  difference  of  the  level  of  two  objects  is 
very  great,  as,  for  instance,  in  extensive  swelling  of  the  disc,  a 
convex  lens  behind  the  mirror  may  be  necessary  before  a  clear 
view  of  the  top  of  the  swelling  is  obtained,  the  refraction 
of  the  eye  being  normal  and  the  fundus  visible  without  a 
lens.  The  difference  between  the  strength  of  the  convex 
lenses  required  to  just  render  objects  indistinct  on  the  level 
of  the  retina  and  on  the  apex  of  the  swelling,  furnishes  a 
measure  of  the  height  of  the  swelling. 

Normally  the  surface  of  the  papilla  is  a  little  anterior  to  the 
plane  of  the  retina,  hence  the  term  "papilla."  The  amount  of 


96  MEDICAL    OPHTHALMOSCOPY. 

this  prominence  varies  in  different  cases.  It  is  always  greater 
where  the  nerve  fibres  are  chiefly  aggregated  in  the  proximity 
of  the  retinal  vessels,  above  and  below,  so  that  a  transverse 
section  through  the  disc  may  show  scarcely  any  appreciable 
prominence,  while  a  vertical  section  may  present  distinct 
prominence.  The  more  closely  the  nerve  fibres  are  aggregated 
in  one  part  of  the  circumference  of  the  nerve,  the  greater  is 
the  prominence.  Occasionally,  but  not  often  in  a  normal 
eye,  it  is  sufficient  to  be  readily  appreciable  by  the  movement 
of  the  head  in  direct  examination.  As  a  rule,  a  promi- 
nence which  is  readily  recognized  is  pathological.  In  morbid 
states,  every  degree  of  elevation  may  be  met  with. 

The  Diagnosis  oj  the  Cause  of  PapilUtis. — The  first  question 
which  presents  itself  in  a  given  case  is — Is  the  neuritis  due 
to  intra- cranial  disease  or  to  some  other  cause  ?  The  answer 
to  this  must,  of  course,  depend  on  the  presence  or  absence  of 
indications  of  disease  of  the  brain,  or  of  such  disease  of  the 
general  system  as  is  known  to  be  accompanied  by  optic 
neuritis.  The  ophthalmoscopic  characters  of  the  neuritis 
will  lead  us  a  little  way,  but  not  far.  A  high  degree  of 
neuritis,  with  intense  strangulation  (such  as  the  discs 
shown  in  PL  VI.  1  and  VIII.  1),  is  seldom  met  with 
except  in  cases  of  cerebral  tumour  and  some  forms  of 
primary  neuritis.  The  slighter  degree  of  neuritis  not 
uncommon  in  cerebral  tumour,  chronic  meningitis,  and 
other  intra-cranial  diseases,  and  the  neuritis  which  occurs 
in  Bright's  disease,  lead  poisoning,  &c.,  may  resemble 
one  another  very  closely.  The  neuritis  of  Bright's  disease 
sometimes  presents  white  spots  in  and  close  to  the  disc,  but 
the  same  appearance  may  be,  and  often  is,  seen  in  the  neuritis 
of  intra-cranial  disease.  (Fig.  7.)  White  spots  in  the  retina 
away  from  the  disc,  with  papillitis  of  a  slight  degree,  and  pre- 
senting no  evidence  of  a  preceding  more  intense  affection,  is 
very  suggestive  of  renal  neuritis.  The  small  cloudy  spots 
seen,  for  instance,  in  PI.  IX.  2  (near  the  left  edge  of  the 
figure) ,  are  of  more  significance  than  the  minute  white  spots 
near  the  macula,  such  as  are  shown  in  PL  IX.  3,  although 
the  latter  are  suggestive  of  renal  disease  when  they  occur  with 


CHANGES    IN    THE    OPTIC    NERVE — NEURITIS.  97 

a  papillitis  of  slight  degree  and  recent  origin.  Succeeding 
neuritis,  or  accompanying  a  neuritis  which  is  subsiding,  they 
are  of  much  less  significance,  being  often  the  relics  of  the 
mischief  caused  by  simple  inflammation ;  and  how  closely 
these  may  simulate  the  appearance  of  a  renal  retinitis  is  shown 
by  Fig.  6  and  PL  VIII.  2.  Although  an  appearance  of  so 
striking  an  aspect  is  very  rare,  a  few  white  spots  near  the 
macula  lutea  are  very  commonly  left  by  neuritis — such  as  are 
seen  in  PI.  VI.  1  and  3.  The  signs  of  a  previous  neuritis  of 
considerable  intensity — a  prominent  mass  of  tissue  in  front  of 
the  disc  such  as  is  seen  there  in  Fig.  3,  or  a  "  filled-in  "  disc 
with  evident  compression  of  vessels,  as  in  PL  VIII.  2 — rarely 
coincide  with  a  similar  appearance  in  renal  retinitis,  although 
such  a  coincidence  is  seen  in  PL  IX.  4.  In  such  a  case  as  is 
there  figured  the  diagnosis  of  the  cause  of  the  neuritis  could 
scarcely  be  made  by  the  ophthalmoscope  alone.  But  attention 
must  always  be  paid  to  the  degree  of  the  present  inflam- 
mation, or  the  evidence  of  its  degree  in  the  past  afforded 
by  the  amount  of  new  tissue  formed. 

It  is  upon  the  independent  signs  of  one  or  the  other  causal 
condition  that  the  diagnosis  must  chiefly  turn.  In  referring 
neuritis  to  cerebral  mischief,  it  must  not  be  forgotten  that, 
on  the  one  hand,  optic  neuritis  due  to  a  cerebral  tumour  may 
be  accompanied  for  a  time  by  no  signs  of  intra-cranial 
disease,  and,  on  the  other  hand,  that  an  optic  neuritis  due 
to  a  general  disease  may  be  accompanied  by  symptoms 
suggestive  of  cerebral  disturbance,  especially  headache, 
vomiting,  and  even,  in  some  cases,  convulsions.  Striking 
instances  of  the  former  were  afforded  by  two  children  whom 
I  saw  at  the  same  time  in  the  Great  Ormond  Street 
Hospital.  One  was  a  boy  under  the  care  of  Dr.  Barlow, 
with  a  tubercular  growth  within  the  right  eyeball,  and 
well-marked  neuritis  to  be  seen  in  the  left  eye  (PL 
III.  4).  The  only  other  symptom  suggestive  of  intra- 
cranial  mischief  was  an  occasional  attack  of  vomiting 
during  many  months  that  he  remained  under  observation. 
The  neuritis  was  of  the  character  highly  suggestive  of  intra- 
cranial  tumour,  but  the  possibility  that  the  mischief  in  one 

H 


98  MEDICAL   OPHTHALMOSCOPY. 

eye  might  have  caused  the  neuritis  in  the  other,  suggested 
extirpation  of  the  eye  which  was  the  seat  of  the  tumour.  It 
had,  however,  no  influence;  and  when  the  boy  died,  about 
a  year  after,  scrofulous  cerebral  tumours  were  found.  The 
other  case  (under  the  care  of  Dr.  Gree)  was  a  child  aged  nine 
years,  who  was'  admitted  having  had  occasional  attacks  of 
headache  and  vomiting.  During  the  intervals  she  seemed 
perfectly  well.  No  symptoms  referable  to  the  nervous  system 
could  be  detected.  She  had,  however,  double  optic  neuritis. 
Gradually  unsteadiness  of  gait  showed  itself,  and  increased 
until  she  was  unable  to  stand,  and  she  ultimately  presented 
all  the  symptoms  of  cerebellar  tumour.  Such  facts  show 
that  the  suspicion  of  intra-cranial  disease  in  cases  of  optic 
neuritis  can  only  be  discarded  after  long  observation,  if 
indeed  it  can  ever  be  given  up  until  some  other  cause  presents 
itself.  This  is  especially  the  case  when  the  neuritis  is 
chronic :  very  acute  neuritis  is  nearly  always  accompanied 
by  symptoms  indicative  of  the  disea.se  causing  it.  Tuber- 
cular tumours  of  the  brain  frequently  cease  to  trouble  the 
patient  or  his  optic  nerves,  and  the  cessation  is  permanent. 
On  the  other  hand,  neuritis  due  to  general  disease  may  be 
accompanied  by  symptoms  suggestive  of  cerebral  mischief. 
The  disc  shown  in  PL  IX.  3  is  that  of  a  man  who  com- 
plained of  almost  constant  severe  headache  and  occasional 
attacks  of  sickness.  The  ophthalmoscope  showed  well-marked 
neuritis,  moderate  in  degree,  and  on  first  inspection  no  retinal 
disturbance  was  detected.  It  was  thought,  for  the  moment, 
to  be  a  case  of  cerebral  tumour.  On  looking  more  carefully 
by  the  direct  method,  however,  near  the  macula  lutea  were 
seen  a  number  of  minute  white  spots  inconsistent  with  the 
slight  degree  of  neuritis.  The  urine  was  at  once  examined, 
and  found  to  be  loaded  with  albumen,  and  on  further 
examination  hypertrophy  of  the  heart  and  a  hard  pulse  were 
found,  with  some  signs  of  ursemic  mischief.  He  died  of 
uraemia  not  long  after.  The  history  of  the  case  shown  at 
PL  IX.  2  is  similar,  except  that  the  evidence  of  cerebral 
disturbance  here  was  mental  change,  not  headache.  Another 
case  impressed  itself  very  strongly  upon  me  many  years 


CHANGES    IN    THE    OPTIC    NERVE NEURTTIS.  99 

ago,  when,  as  a  resident  in  University  College  Hospital, 
I  was  first  working  with  the  ophthalmoscope.  A  man  was 
admitted  with  convulsions,  and  comatose.  An  examination  of 
the  eyes  showed  double  optic  neuritis,  and  a  diagnosis  of 
cerebral  tumour  was  at  once  ventured  on.  The  patient  died 
in  a  few  hours,  and  the  necropsy  revealed  contracted  kidneys 
and  a  normal  brain.  A  mistake  of  this  kind  is  easily  made, 
especially  if  the  examination  is  confined  to  the  indirect 
method;  but  I  think  that  the  mistake  may  generally  be 
avoided  by  the  direct  method  of  examination ,  which  has,  in 
all  cases  I  have  since  seen,  disclosed  slight  retinal  alteration 
inconsistent  with  the  form  of  the  neuritis.  Examination 
of  the  urine  should,  of  course,  never  be  neglected. 

Headache  and  vomiting  are,  then,  the  signs  of  least  value  as 
indications  of  an  intra-cranial  cause  of  neuritis.  Convulsion 
is  also  of  little  value  unless  it  is  of  a  form  which  indicates  local 
brain  disease,  i.e.,  local  in  distribution  or  in  commencement. 

In  all  obscure  cases,  search  must  be  made  for  any  other 
cause  of  optic  neuritis,  especially  lead  poisoning.  In  cases  of 
lead  poisoning  renal  disease  is  very  frequent,  and  that  cause 
for  neuritis  must  be  excluded  before  the  affection  can  be 
referred  to  plumbism.  In  these  cases  also  doubt  may  be  felt 
as  to  whether  the  mischief  is  not  due  to  cerebral  disease, 
because  lead  poisoning  is  sometimes  accompanied  with  two 
forms  of  cerebral  disturbance — delirium  and  convulsion.  In 
the  case  presenting  the  neuritis  shown  in  PL  VII.  6  there 
was  extreme  cerebral  disturbance,  apparently  the  consequence 
of  the  lead  poisoning  ;  and,  on  the  other  hand,  I  have  lately 
had  under  my  care  several  cases  in  which  recurring  con- 
vulsions, precisely  like  those  of  idiopathic  epilepsy,  were  due 
to  the  same  cause. 

One  other  fact  must  be  mentioned  in  connection  with  the 
diagnosis  of  the  cause  of  optic  neuritis.  In  many  cases  in 
which  slight  neuritis  of  chronic  course  is  associated  with 
symptoms  which  would  scarcely  suggest  the  existence  of 
disease  such  as  would  cause  neuritis,  hypermetropia  exists. 
This  combination  may  be  noted,  for  instance,  in  chlorosis  (as 
in  the  case  figured  in  PL  VII.  5),  in  epilepsy,  apparently 


100  MEDICAL   OPHTHALMOSCOPY. 

idiopathic,  and  other  slight  symptoms  of  cerebral  disturbance. 
It  is  doubtful,  in  the  present  state  of  our  knowledge,  what 
share  is  to  be  attributed  to  the  hypermetropia  in  the  pro- 
duction of  the  neuritis,  and  from  the  commonness  of  hyper- 
metropia the  coincidence  may  have  been  accidental,  but  the 
fact  deserves  notice. 

PROGNOSIS. — The  prognosis  in  optic  neuritis  is  necessarily 
a  source  of  considerable  anxiety.  In  few  cases  can  it  be 
said  that  vision  is  not  in  danger  of  impairment  and  even 
of  loss.  The  prognosis  must  be  formed  by  a  careful  study 
of  the  conditions  on  which  impairment  of  sight  depends, 
as  stated  on  p.  72.  The  prospect  is  better  in  the  slighter 
degrees  of  papillitis,  and  better  in  proportion  to  clironicity  of 
course,  and  dependence  on  causes  which  can  be  treated.  It 
is  worse  when  there  is  reason  to  believe  that  there  is  much 
retro-ocular  mischief ;  worse  in  proportion  to  the  evidence  the 
ophthalmoscope  affords  of  a  process  of  compression  going  on 
in  the  disc ;  worse  in  proportion  to  the  intensity  of  the 
changes  ;  and  worse  in  the  loss  of  sight  which  comes  on 
during  the  recession  of  the  inflammation  than  in  that  which 
comes  on  during  its  height. 

The  cause  of  the  optic  neuritis  must  influence  our  prognosis 
more  than  any  other  condition.  It  is  better  in  syphilitic  than 
in  scrofulous  cases,  and  better  in  these  than  in  cases  of 
disease  of  other  forms.  Even  in  syphilitic  mischief,  however, 
the  prognosis  must  be  guarded  if  the  intra-ocular  changes 
are  considerable.  It  is  not  probable  that  the  optic  neuritis 
is,  itself,  syphilitic  in  nature.  Its  subsidence  depends  rather 
on  the  subsidence  of  the  syphilitic  intra-cranial  disease,  than 
on  the  influence  of  the  remedy  on  the  intra-ocular  process, 
and  it  is  not  uncommon  to  have  considerable  failure  of  sight 
during  the  subsidence  of  the  neuritis  in  such  cases.  For- 
tunately when  the  subsidence  of  the  neuritis  has  ceased,  there 
is  a  greater  tendency  to  improvement  of  vision,  and  this 
may  be  considerable  in  degree  (see  "  Consecutive  Atrophy  "). 

TREATMENT. — Very  little  can  be  done  for  the  direct  treat- 


CHANGES    IN    THE    OPTIC    NERVE NEURITIS.  101 

ment  of  optic  neuritis.  The  treatment  is  that  of  the  intra- 
cranial  mischief,  or  general  disease,  which  is  its  cause. 
Beyond  this,  local  measures,  leeches  and  the  like,  are  little 
likely  to  influence  the  progress  of  the  disease.  The  puncture 
of  the  distended  nerve-sheath  has  been  advocated  by  De 
"Wecker,  and  performed  by  him  and  by  Mr.  Power,  and 
recently  in  a  number  of  cases  by  Mr.  Brudenell  Carter  and 
Mr.  Bickerton.1  It  is  based  on  the  theory  that  the  distension 
of  the  sheath  is  the  cause  of  the  intra-ocular  neuritis,  a  theory 
which,  it  has  been  seen,  cannot  yet  be  considered  as  proved. 
Improvement  has  followed  the  operation  in  a  few  of  the 
cases,  but  it  must  be  tried  in  a  much  larger  number  of  cases 
before  a  decisive  opinion  can  be  formed. 

During  neuritis  the  eyes  should  be  used  as  little  as  may  be, 
and  such  conditions  as  intensify  intra-ocular  congestion  should 
be  avoided,  e.g.,  exposure  to  cold,  and  all  causes  of  mechanical 
congestion,  straining,  cough,  &c.  Ice  to  the  forehead  has 
been  recommended  by  Pfliiger. 

Optic  neuritis  is  so  frequently  associated  with  syphilitic 
disease  of  the  brain  and  its  membranes,  and  the  evidence 
which  may  seem  to  exclude  the  suspicion  of  syphilis  is  so 
often  misleading,  that  the  administration  of  iodide  of  potassium 
should  be  a  rule  in  almost  all  cases  in  which  the  age  of  the 
patient  is  such  that  acquired  syphilis  is  possible.  Iodide,  in 
large  doses,  secures  a  more  prompt  improvement  than  mercury, 
and  does  no  harm  if  the  disease  is  not  syphilitic  in  nature. 
Additional  benefit  may,  however,  result  from  the  subsequent 
use  of  mercury.  The  completeness  of  recovery  depends  on  the 
promptness  with  which  the  progress  of  the  disease  can  be 
checked.  Even  in  syphilitic  cases  it  must  be  remembered 
that,  the  intra-ocular  neuritis  being  probably  not  syphilitic  in 
nature,  although  the  consequence  of  syphilitic  brain  disease, 
the  remedy  employed  does  not  influence  the  inflammatory 
products  in  the  papilla,  as  it  does  the  disease  in  the  brain. 
As  it  has  just  been  stated,  in  many  cases  of  syphilitic  disease 
of  the  brain  with  optic  neuritis,  in  which  the  cerebral  symp- 
toms have  cleared,  and  the  neuritis  has  subsided  under 
1  "  Oph.  Rev.,"  1888,  vol.  vii.  p.  300. 


102  MEDICAL   OPHTHALMOSCOPY. 

appropriate  treatment,  sight  has  become  damaged  during  the 
subsidence  of  the  neuritis,  apparently  very  much  as  it  would 
have  done  had  the  cerebral  disease  not  been  syphilitic  in 
nature.  It  is  the  recession  of  the  cerebral  trouble  which 
permits  the  recession  of  the  neuritis,  and  the  ocular  damage 
bears,  in  most  cases,  a  direct  proportion  to  its  duration. 
Hughlings- Jackson  believes  that  iodide  of  potassium  is  some- 
times useful  when  there  is  no  syphilis.  lodoform,  internally 
and  externally,  has  been  advocated  by  Landesberg. 

Where  the  disease  is  not  syphilitic  it  is  often  scrofulous, 
and  here  also  great  good  can  be  done  by  appropriate — 
especially  tonic — treatment.  Commencing  neuritis  may 
subside  entirely  and  leave  no  trace,  under  the  influence  of 
such  treatment.  But  unfortunately  we  are  able  to  influence 
such  disease  much  more  slowly  than  we  can  influence 
syphilitic  disease,  and  if  neuritis  be  already  well  developed, 
it  is  rarely  that  loss  of  sight  can  be  prevented. 

B.— MORBID  STATES  OF  THE  OPTIC  DISC  CHARACTERIZED 
USUALLY  BY  LESSENED  VASCULARITY  AND  SIGNS  OF 
WASTING.  ATROPHY  OF  THE  OPTIC  NERVE. 

Under  many  circumstances  the  fibres  of  the  optic  nerves 
undergo  wasting  or  degeneration.  This  occurs  when  the  eye 
has  been  greatly  damaged  by  any  cause,  and  possibly  when 
complete  opacity  has  rendered  the  cornea  or  lens,  for  a  long 
time,  impermeable  to  rays  of  light.  It  has  been  seen  to  occur 
as  a  consequence  of  the  inflammation  of  the  intra-ocular  end 
of  the  nerve,  or  of  its  whole  trunk ;  the  wasting  thus  produced 
is  termed  "  consecutive,"  "  post-papillitic,"  or  "  post-neuritic 
atrophy."  In  other  cases  the  wasting  is  preceded  by  no 
visible  inflammatory  disturbance,  and  such  are  termed  "simple 
atrophy."  Nevertheless,  in  rare  cases,  an  atrophy  is  preceded 
by  the  signs  of  simple  congestion  of  the  disc,  and  such  cases 
may  be  termed  "  congestive  atrophy."  It  is  probable  that 
the  pathological  condition  of  the  optic  nerve  in  this  form  is 
really  a  chronic  inflammation,  partial  or  diffuse,  of  which  the 
intra-ocular  signs  of  congestion,  &c.,  are  the  indication,  but 


CHANGES    IN    THE    OPTIC    NERVE  -  ATROPHY.  103 

it  is  convenient,  for  clinical  reasons,  to  consider  it  among  the 
forms  of  atrophy.  Lastly,  atrophy  may  succeed  choroiditis 
and  retinal  disease. 

Atrophy,  not  consequent  on  any  obvious  ocular  change, 
was  found  by  Vulpian  in  about  4  per  cent.  (19  out  of  500) 
autopsies  on  old  persons  at  the  Salpetriere.  In  an  equal 
number  (21)  there  was  atrophy  consequent  on  an  ocular 
disease.1 


S.  —  The  nutrition  of  the  nerve  fibres,  and  that  of 
the  capillary  vessels  which  confer  on  the  disc  its  normal  rosy 
tint,  are  so  associated  that  atrophy  of  the  fibres  is  accompanied 
in  nearly  all  cases  by  an  atrophy  of  the  capillaries,  and  the 
pallor  thus  produced  constitutes  the  most  salient  sign  of  the 
atrophy  of  the  nerve.  The  atrophied  nerve  commonly  shrinks, 
and  occupies  less  bulk  than  the  normal  nerve.  This  is  not 
attended  by  any  diminution  in  the  size  of  the  optic  disc,  since 
the  latter  is  determined  by  the  size  of  the  sclerotic  opening. 
The  shrinking  is  indicated  by  a  slight  recession  or  "  excava- 
tion "  of  the  disc.  In  some  cases  there  is  a  diminution  in 
size  of  the  retinal  vessels,  but  this  is  an  inconstant  character. 
These  signs  will  be  considered  in  detail. 

Pallor.  —  The  vascularity  of  the  optic  nerve,  as  has  been 
before  pointed  out,  is  estimated  by  the  tint  of  its  intra-ocular 
termination,  the  "  optic  disc."  In  judging  of  the  colour  of 
the  disc  it  is  important  to  examine  it  with  a  weak  illumination, 
and  by  the  direct  method,  in  order  to  let  as  little  light  as 
possible  be  reflected.  In  a  strong  light  a  faintly-tinted 
object  will  appear  white.2  Hence  the  importance,  to  recog- 
nize a  slight  coloration,  of  employing  a  weak  illumination. 
The  ophthalmoscope  of  Helmholtz,  consisting  of  plates  of 

1  Table  given  by  Galezowski,  '  '  Sur  les  Atrophies  de  la  Papille  du  N"erf 
Optique."     "  Journal  d'Ophtalmologie,"  Jan.,  Feb.,  and  March,  1872. 

2  With  very  intense    illumination,   even   a  strongly-tinted    object    will 
appear  white.     This  is   because  all   objects  reflect   some   of  all   rays,   and 
absorb  none  entirely.     If  the  waves  impinging  be  sufficiently  numerous  — 
i.e.,  the  light  very  intense  —  so  many  waves  of  all  lengths  are  reflected  that 
the  object  appears  white,  the  waves  of  the  length  chiefly  reflected  being  no 
longer  preponderant,  although  they  become  preponderant  on  weakening  the 
light. 


104  MEDICAL    OPHTHALMOSCOPY. 

thin  glass,  is  especially  useful  for  this  purpose.  A  plane 
mirror  may  be  employed  instead.  If  this  is  not  available, 
the  light  of  the  illuminating  lamp  should  be  turned  low. 

It  is  as  essential  to  be  aware  of  the  normal  variations  in 
colour  for  the  estimation  of  a  pathological  pallor  of  the  optic 
disc,  as  it  is  for  the  recognition  of  congestion.  The  varia- 
tions on  the  negative  side  are  not,  perhaps,  so  considerable 
as  are  those  on  the  positive  side,  but  they  are  sufficient  to 
render  familiarity  with  the  appearance  of  the  normal  disc 
essential  to  prevent  mistakes  in  estimating  the  slighter  degrees 
of  atrophy.  As  a  rule,  the  disc  becomes  paler  as  life  advances, 
and  a  slight  grey  tint  becomes  mingled  with  the  red,  but  the 
latter  is  still  perceptible.  The  physiological  cup,  if  slight, 
is  often  indistinct  late  in  life.  Thus,  a  tint  which  is  normal 
in  the  old,  would  be  suggestive  of  atrophy  in  the  young. 
Again,  when  the  general  fundus  is  unusually  dark,  the  disc 
will  seem  to  be  abnormally  pale,  simply  as  an  effect  of  con- 
trast. In  anaemia,  also,  the  disc  may  become  paler,  but  the 
change  of  tint  from  this  cause  is  not  considerable,  and  is 
insignificant  in  comparison  with  the  normal  variations  in 
colour  of  the  disc.  It  never  constitutes  an  element  of 
difficulty  in  the  recognition  of  atrophy. 

When  a  pathological  pallor  of  the  disc  is  pronounced, 
it  extends  over  the  whole  area  of  the  disc,  but  commencing 
pallor  may  be  most  marked  in  that  part  of  the  disc  which  is 
normally  palest,  i.e.,  the  temporal  side,  where  the  nerve  fibres 
are  least  numerous.  The  change  in  this  part,  however,  is  only 
of  significance  in  individuals  in  whom  the  "physiological 
cup  "  is  small,  and  the  temporal  half  of  the  disc  normally 
possesses  a  distinctly  vascular  tint.  In  a  great  number  of 
cases,  in  which  the  physiological  excavation  is  large,  and 
slopes  gradually  to  the  sclerotic  ring  on  the  temporal  side, 
this  portion  of  the  disc  may  be  normally  almost  as  pale  as  in 
atrophy.  The  part  on  which  attention  should  be  chiefly  fixed 
is,  therefore,  that  which  normally  possesses  considerable 
vascularity,  the  nasal  portion.  The  tint  may  be  observed  to 
become  gradually  paler,  the  red  sometimes  simply  fading,  and 
leaving  a  white  colour  in  its  place ;  in  other  cases  a  grey 


CHANGES    IN    THE    OPTIC    NERVE ATROPHY.  105 

becomes  mingled  with  the  red,  and  gradually  preponderates 
as  the  red  tint  fades,  and  ultimately  a  pure  grey  is  left. 
If  the  examination  is  made  with  daylight,  the  tint  is  often 
a  greenish-grey.  These  two  varieties  constitute  in  their 
extreme  forms  the  white  and  grey  forms  of  atrophy  respec- 
tively. Intermediate  forms  are  often  seen,  and  to  the  direct 
method  of  examination  some  grey  tint  may  always  be  dis- 
tinguished, even  in  the  discs  which  appear  of  tendinous  or 
chalky  whiteness  to  the  indirect  method  of  examination. 
This  grey  mottling  tends  to  increase  as  time  goes  on.  The 
slight  grey  tint  in  "  white  atrophy "  is  similar  to  that 
normally  seen  at  the  bottom  of  the  physiological  cup.  This 
tint  is,  however,  scattered  over  the  disc,  and  the  central  cup 
is  often  distinguishably  whiter  or  greyer  than  the  rest. 

The  aspect  of  the  disc,  whether  white  or  grey,  is  not 
definitely  related  to  the  form  or  cause  of  the  atrophy,  and 
hence  it  is  undesirable  to  employ  it  as  a  basis  for  classification. 

The  atrophy  leaves  the  edge  of  the  disc  very  distinct  and 
sharp.  The  sclerotic  ring  is  much  more  clear  than  it  is 
normally,  but  it  may  not  at  first  be  recognized  by  the  indirect 
method,  as  it  is  not  differentiated  from  the  white  surface,  as 
it  is  from  the  rosy  tint  of  the  normal  disc.  The  sharpness 
of  the  edge  is  due,  not  only  to  its  clearness,  but  also  to  the 
fact  that  the  choroid  preserves  its  normal  characters  to  the 
margin,  and  gives  to  the  clear  outline  a  peculiar  sharp-cut 
aspect,  which  is  the  characteristic  of  "  simple  atrophy." 
Pigmentary  deposits  on  the  edge  of  the  disc  are,  like  the 
edge  itself,  abnormally  distinct. 

Excavation. — In  simple  atrophy  of  the  nerve,  the  surface 
of  the  disc  is  depressed  in  proportion  to  the  wasting  of  the 
nerve-trunk.  This  varies,  however,  in  the  different  forms  of 
atrophy,  because  the  wasting  of  the  nerve  fibres  is,  in  some 
forms,  combined  with  wasting  of  the  connective  elements,  and 
a  great  shrinking  of  the  nerve  in  size,  while  in  other  cases  the 
wasting  of  the  fibres  is  accompanied  with  an  overgrowth  of 
connective  tissue,  which  may  to  some  extent  compensate  for 
the  shrinking  due  to  the  atrophy  of  the  nerve  elements,  and 
may  even  prevent  any  diminution  in  bulk  of  the  nerve.. 


106  MEDICAL   OPHTHALMOSCOPY. 

Thus,  in  some  cases,  the  depression  of  the  disc  is  considerable, 
and  in  others  it  is  slight  or  absent.  Its  special  character  is 
that  it  affects  the  whole  disc,  and  commences  at  the  sclerotic 
ring.  It  may  often  be  recognized  by  the  change  of  level  of 
the  retinal  vessels  at  the  spot,  most  distinct  on  lateral  move- 
ment of  the  observer's  head.  Normally,  it  will  be  remembered, 
the  depression  of  the  centre  of  the  disc  never  begins  at  the 
sclerotic  ring,  except  that  in  some  cases  of  large  normal  cups 
it  may  commence  at  the  ring  on  the  temporal  side.  Above, 
below,  and  at  the  nasal  side — i.e.,  in  the  position  of  the  large 
vessels — the  normal  excavation  never  commences  at  the  ring, 
within  which  there  is  always  a  zone  of  nerve  tissue,  commonly 
the  most  prominent  portion  of  the  disc.  Hence  the  change 
of  level  of  the  large  vessels  at  the  ring  becomes  an  important 
sign  of  tfce  atrophic  excavation.  The  size  and  form  of  the 
resulting  excavation  depend  on  two  things — the  amount  of 
shrinking  of  the  nerve,  and  the  size  and  form  of  the  normal 
cup.  The  wasting  of  the  edge  of  the  cup  tends  to  lessen  the 
steepness  of  the  side  or  sides,  and  to  give  its  form  a  funnel 
shape. 

The  mottling  of  the  lamina  cribrosa  may  become  very 
distinct  at  the  bottom  of  the  excavation,  and  this  in  some 
cases,  it  is  said,  in  which  before  the  atrophy  no  physiological 
depression  existed.  Where  the  normal  cup  was  large,  the 
excavation  may  reveal  the  lamina  cribrosa  in  almost  the  whole 
extent  of  the  disc,  the  grey  mottling  corresponding  to  the 
bundles  of  degenerated  nerve  fibres,  the  white  intervals  to 
the  meshes  of  the  lamina. 

It  is  believed  that  some  share  in  the  excavation  is  due  to 
the  atrophy  of  the  small  vessels,  which  conferred  on  the 
normal  disc  a  certain  amount  of  turgescence.  De  Wecker 
suggests  that  as  the  nerve  has  its  consistence  lessened,  the 
normal  intra-ocular  pressure  may  assist  in  producing  the 
excavation. 

It  has  been  said  that  the  more  connective  tissue  is  deve- 
loped in  the  atrophied  nerve,  the  slighter  is  the  shrinking 
of  the  trunk.  This  is  especially  the  case  in  the  grey  atrophy, 
in  which  the  nerve  may  retain  its  normal  size.  The  de- 


CHANGES    IN    THE    OPTIC    NERVE ATROPHY.  107 

pression  in  the  disc  may  be  less  in  these  cases  than  in  the 
whiter  form  of  simple  atrophy,  but  it  is  not,  as  has  been  said, 
absent,  and  it  is  often  considerable.  Among  the  remains  of 
the  diverging  nerve  fibres,  there  is  little  connective  tissue 
developed,  and  the  wasting  of  the  fibres  here  is  compensated 
for  to  a  much  less  extent  than  in  the  trunk  of  the  nerve. 

The  Retinal  Vessels. — In  some  cases  of  simple  atrophy  of 
the  optic  nerve  the  retinal  vessels  become  reduced  in  size,  in 
others  they  do  not.  In  the  grey  atrophy,  as  a  rule,  the 
vessels  undergo  little  or  no  change,  but  they  are  occasion- 
ally narrowed.  In  simple  white  atrophy  they  present  no 
alteration  in  some  cases ;  in  others,  the  arteries  gradually 
become  smaller,  the  veins  undergoing  little  diminution. 
After  a  time  the  veins  also  may  shrink.  They  are  reduced 
in  size  in  cases  in  which  there  is  a  retro-ocular  neuritic 
process,  but  this,  without  evidence  of  neuritis  in  the  disc, 
cannot  be  regarded  as  the  cause  of  their  shrinking  in  all 
cases.  Their  atrophy  seems  sometimes  to  be  part  of  the 
atrophy  of  the  nerve-fibre  and  ganglion-cell  layers  of  the 
retina,  which  is  usually  associated  with  atrophy  of  the  nerve. 
Why  they  should  shrink  in  some  cases  and  not  in  others  is  at 
present  unexplained. 

Initial  Signs  of  Congestion. — In  describing  simple  conges- 
tion of  the  disc,  it  was  pointed  out  that  it  may  terminate  in 
atrophy.  The  disc  has,  at  first,  a  dull-red  tint,  with  a  soft- 
looking  surface,  the  redness  being  uniformly  distributed  over 
it.  The  edges  of  the  disc  are  less  sharply  defined  than 
in  health;  they  are  visible,  but  are  softened.  It  is  this 
uniform  distribution  of  the  tint,  and  softness  of  the  edge, 
which  give  to  the  disc  its  special  character.  The  congestion 
may  persist  for  a  long  time,  but  commonly,  as  time  goes  on, 
the  disc  slowly  becomes  paler,  and  ultimately  a  condition  of 
greyish-white  atrophy  is  reached.  Occasionally  the  disc 
presents  at  first,  for  a  short  time,  a  slight  degree  of  oedema 
as  well  as  congestion,  shown  by  slight  swelling.  The  patho- 
logical process,  in  many  cases  of  atrophy,  seems  to  be  of  the 
nature  of  a  chronic  inflammation.  It  is  readily  intelligible 
that  in  some  cases  the  signs  of  slight  inflammation  should  be 


108 


MEDICAL    OPHTHALMOSCOPY. 


visible  in  the  disc  during  the  early  stage.  The  cases  in  which 
it  is  met  with  are  especially  those  which  result  from  injury 
and  from  toxic  causes.  This  state  of  chronic  inflammation 
behind  the  eye,  retro-ocular  neuritis,  may  be  diffuse  and 
affect  the  whole  nerve,  or  partial  and  involve  only  a 
segment  of  the  nerve  (segmental  neuritis),  or  its  central 
portion  (axial  neuritis).  The  vessels  often  present  much 
earlier  and  more  considerable  narrowing  than  in  simple 
atrophy,  and  in  the  disc  around  them  much  white  tissue 
becomes  developed.  It  is  to  be  noted,  however,  that  in  some 
conditions  of  undoubted  retro-ocular  neuritis,  there  may  be 
no  signs  of  inflammation  or  congestion  of  the  disc,  but  only 
that  of  simple  atrophy,  and  hence  it  is  convenient  to  consider 
this  form  in  the  present  section.  The  mischief  is  commonly 
at  some  distance  behind  the  eye. 

Atrophy  after  Intra- Ocular  Neuritis  ;  "Consecutive  Atrophy" 
or  "  Papittitic  Atrophy" — The  newly-formed  inflammatory 
tissue-elements  of  papillitis  are  in  part  removed,  and  in  part 
transformed  into  connective  tissue,  which  gradually  shrinks. 
The  pale  swelling  left  by  the  inflammation  (PL  II.  1,  IY.  5, 
VI.  3),  large  in  proportion  to  the  intensity  of  the  process, 
slowly  subsides,  until  it  is  confined  within  the  limits  of  the 
disc,  and  slowly  reaches  the  level  of  the  retina  (Fig.  49). 
The  soft  edges  which  at  first  limit  the  pale  swelling  gradually 
become  more  sharply  defined.  The  recession  of  the  swelling 


FIG.  49. — VERTICAL  SECTION  THROUGH  THE  OPTIC  Disc  ix  A  CASE  OF 
POST-PAPILLITIC  ATROPHY,  DUE  TO  TUBERCLE  OF  THE  CEREBELLUM. 

The  retinal  layers  are  displaced,  and  the  bundles  of  fibres  in  the  optic  nerve 
are  separated.  A  vessel  is  seen  divided  longitudinally.  Neither  within 
nor  behind  the  sclerotic  ring  is  it  compressed.  Within  the  papilla,  how- 
ever, its  branches  are  very  narrow,  (x  15.) 


CHANGES  IX  THE  OPTIC  NERVE— ATROPHY.      109 

from  the  edge  of  the  choroid  often  shows  that  the  latter 
has  been  damaged,  and  has  undergone  irregular  atrophy 
adjacent  to  the  edge  of  the  disc  (PI.  II.  4,  IY.  4),  which 
thus  has  a  more  or  less  irregular  outline.  The  substance  of 
the  disc  has  a  "  filled-in  "  look,  from  the  new  tissue  within  it 
(PL  VIII.  2),  and  is  commonly  white,  or  rarely  greyish 
in  tint  (PI.  II.  2,  upper  half).  The  vessels,  whether  pre- 
viously narrowed  or  not,  usually  become  narrowed  by  the 
contraction  of  this  new  tissue,  and  may  be  partly  concealed 
by  it  at  their  origin,  or  in  their  course  over  the  disc.  The 
tissue  along  their  walls  is  often  distinctly  whiter  than  the 
rest  of  the  disc,  and  when  the  latter  is  grey  the  contrast 
between  it  and  the  perivascular  tissue  may  be  very  marked 
(PI.  II.  2).  Often  white  lines  are  to  be  traced  along  the 
narrowed  vessels  for  some  distance  from  the  disc  (PL  II.  4) . 
They  are  probably  due  to  thickening  of  the  outer  coat, 
perhaps  originating  in  the  migration  of  white  corpuscles 
along  the  perivascular  sheaths  (Fig.  11),  and  the  trans- 
formation of  these  into  connective-tissue  elements.  Ulti- 
mately, the  contraction  of  the  tissue  may  cause  an  excavation 
of  the  disc,  even  in  the  centre  (PL  II.  4,  IY.  6),  and  there 
is  only  the  adjacent  choroidal  disturbance  and  the  narrowing 
of  the  vessels,  to  indicate  the  origin  of  the  atrophy.  The 
excavation  rarely,  however,  becomes  sufficient  to  reveal  the 
lamina  cribrosa.  (Of.  Figs.  3  and  4,  PL  II.)  The  disc 
usually  remains  for  a  long  time  white  to  the  indirect  examina- 
tion ;  sometimes  its  tint  is  slightly  rosy.  Ultimately,  however, 


FIG.  50. — SECTION  THROUGH  THE  OPTIC  NERVE  IN  THE  SAME  CASE  AS 

THE  PRECEDING  FlGTJRE. 

The  fasciculi  of  degenerated  nerve  fibres  are  infiltrated  with  nuclei,  and  cells 
of  irregular  shape.    The  septa  between  the  bundles  are  a  little  thickened. 
x  100.) 


110  MEDICAL    OPHTHALMOSCOPY. 

it  becomes  distinctly  greyish,  especially  on  direct  examination, 
and  with  feeble  illumination.  In  some  cases  the  inflammation 
may  not  have  damaged  the  choroid,  although  causing  destruc- 
tion of  the  nerve  fibres,  and  in  such  a  case  the  edge  of  the 
disc  may  be  sharply  defined,  and  if,  as  is  the  case  sometimes 
when  the  inflammation  is  moderate,  the  narrowing  of  the 
vessels  is  slight  in  degree,  the  appearance  of  the  disc  may 
resemble  very  closely  the  disc  in  simple  atrophy,  and  be  quite 
indistinguishable  from  that  left  by  retro-ocular  neuritis. 

Choroiditic  Atrophy. — The  atrophy  of  the  disc,  which  is 
often  seen  after  choroido-retinitis,  is  sometimes  white  or 
grey  and  resembles  primary  atrophy ;  but  sometimes  it 
presents  special  features,  being  characterized  by  a  peculiar 
reddish,  or  yellowish-red  tint  of  disc,  uniform  in  distribu- 
tion, sometimes  with  slight  blurring  of  its  edges,  and  usually 
by  a  marked  wasting  of  the  retinal  vessels,  which  may  be 
diminished  in  number  as  well  as  in  size. 

The  recognition  of  this  variety  of  choroiditic  atrophy  is  of 
considerable  importance,  because,  unless  the  result  of  retinitis 
pigmentosa,  it  is  almost  always  the  consequence  of  syphilitic 
disease,  acquired,  or  more  frequently,  inherited.  It  con- 
stitutes a  sign  of  inherited  syphilis  of  great  importance.  In 
most  cases  the  disturbance  of  the  retinal  pigment  is 
distinct  and  characteristic. 

CAUSES. — Simple  atrophy  of  the  optic  nerve  may  be  a 
primary  change,  or  may  be  secondary  to  some  lesion,  trau- 
matic or  other,  which  interferes  with  the  structural  integrity 
of  the  nerve.  These  two  varieties  may  be  distinguished  as 
"  primary"  and  "  secondary"  atrophy,  and  are  especially  cha- 
racterized by  the  circumstance  that  in  primary  atrophy  the 
loss  of  sight  coincides  in  origin  and  progress  with  the  visible 
atrophy,  but  in  secondary  atrophy  the  loss  of  sight  occurs 
first,  and  the  signs  of  nerve  degeneration  are  not .  observed 
until  a  subsequent  period.  It  is  doubtful  whether  the  two 
forms  can  be  distinguished  by  the  ultimate  aspect  of  the  disc. 

It  has  been  proposed  to  divide  the  primary  atrophies  into  two 
classes,  according  as  the  process  commences  by  degeneration 


CHANGES    IN    THE    OPTIC    NERVE ATROPHY.  Ill 

of  the  nerve  elements,  or  by  growth  of  the  interstitial  tissue, 
with  secondary  damage  to  the  nerve  fibres.  The  distinction 
has  been  especially  insisted  on  by  Charcot  and  by  Abadie, 
on  grounds  of  etiology,  pathology,  and  symptoms.  Our 
knowledge  at  present  is  scarcely  sufficiently  definite  to  make 
a  sharp  distinction  generally  useful,  if  indeed  it  is  founded 
on  a  correct  basis.  The  careful  discussion  of  the  subject 
by  Duwez  deserves  perusal.1 

Primary  Atrophy  often  comes  on  without  known  causes. 
It  is  sometimes,  however,  distinctly  hereditary,  and  one  very 
remarkable  form  (carefully  studied  by  Leber)  affects  all  the 
males  of  a  family  soon  after  puberty.  The  atrophy  is  here  really 
preceded  by  a  slight  neuritis,  and  its  occurrence  seems  to  be 
associated  with  a  neuropathic  type  of  family.2  The  male  sex 
is,  apart  from  this  variety,  more  prone  to  optic  nerve  atrophy 
than  the  female.  Seventy-five  per  cent,  of  all  cases  occur  in 
men,  and  most  cases  occur  in  adults.  A  considerable  number 
of  the  cases  of  primary  atrophy  are  associated  with  spinal 
disease  and  are  distinguished  as  "  spinal  atrophies."  Cases 
of  optic  nerve  atrophy,  in  which  there  are  no  .symptoms  of 
other  affection  of  the  nervous  system,  are  usually  classed  as 
"  simple  progressive  atrophy  " — an  inconvenient  designation, 
since  the  cases  of  spinal  atrophy  are  also  progressive.  The 
class  probably  includes  several  distinct  forms  which  are  not 
yet  differentiated. 

The  group  of  "  spinal  atrophies  "  of  the  optic  nerve  is  of 
great  medical  interest  and  practical  importance.  The  most 
important  is  the  atrophy  which  so  often  accompanies  loco- 
motor  ataxy.  This  form  is  regarded  as  the  most  typical 
example  of  the  "  parenchymatous,"  i.e.,  primarily  neural 
form.  It  is  usually  a  grey  atrophy  in  ophthalmoscopic 
aspect,  without  diminution  in  the  size  of  the  vessels.  A 
large  number  of  primary  atrophies  are  of  this  variety.  The 
tabetic  symptoms  may  be  long  delayed,  and  many  such  cases 

1  In  the    "  Dictionnaire   Encyclopedique  des   Sciences   Med.,"  torn.   xvi. 
pt.  1,  p.  319. 

2  See  also  a  paper  on  this  subject  by  S.  H.  Habershon  :  "Trans.   Ophth. 
Soc.,"  vol.  viii.  1888,  p.  190. 


112  MEDICAL    OPHTHALMOSCOPY. 

have  been  regarded  as  independent  atrophy  (see  Part  II., 
"  Diseases  of  the  Spinal  Cord  ").  It  has  been  indeed  suggested 
by  Charcot  that  almost  all  cases  of  primary  atrophy  are  of 
this  form,  that  the  subjects  of  them,  if  they  do  not  present 
spinal  symptoms  when  seen,  will  do  so  at  a  future  period. 
This  is  certainly  incorrect.  It  is  probable,  from  the  facts 
observed  by  Uhthoff,1  that  not  more  than  one-half  of  the 
cases  of  primary  atrophy  are  associated  with  disease  of  the 
spinal  cord. 

A  similar  atrophy  may  be  observed  occasionally  in  general 
paralysis  of  the  insane,  and  also,  although  rarely,  in  dissemi- 
nated (insular)  sclerosis,  and  in  lateral  sclerosis  of  the  cord. 
The  form  which  occurs  in  general  paralysis  is  described  by 
Clifford  Allbutt  as  often  preceded  by  distinct  signs  of  con- 
gestion of  the  disc.  This  is  doubted  by  many,  and  is  certainly 
very  often  not  to  be  observed,  but  in  one  or  two  cases  I  have 
seen  marked  congestion  of  the  discs  in  general  paralysis, 
although  unable  to  follow  them  to  the  atrophic  stage. 

The  pathology  of  the  connection  of  the  optic  nerve  atrophy 
and  the  spinal  cord  changes  is  still  obscure.  The  fact  that 
in  locomotor  ataxy  the  atrophy  may  reach  an  advanced 
degree  when  the  change  in  the  spinal  cord  is  still  in  its 
earliest  stage,  and  even  when  the  latter  is  confined  to  the 
lowest  part,  makes  it  probable  that  the  optic  change  is  an 
associated  and  not  a  sequential  lesion.  At  present  this  pro- 
bability is  not  lessened  by  the  discovery  of  J.  Stilling2  that 
some  fibres  of  the  optic  nerve  can  be  traced  into  the  medulla 
oblongata  as  far  as  the  inferior  olivary  body. 

It  must  be  remembered  that  the  optic  nerve  is,  develop- 
mentally,  a  direct  prolongation  of  the  central  nervous  system, 
and  that,  anatomically,  it  resembles  the  white  matter  of  the 
brain  and  spinal  cord.  The  importance  of  this  relationship, 
in  connection  with  the  question  of  the  independent  origin 
of  changes  in  the  optic  nerves  and  in  the  spinal  cord,  has 
been  called  attention  to  by  Grunn.3 

1  "Arch.  f.  Ophth.,"  vol.  xxvi.  1881,  pt.  1,  p.  277. 

2  "  Centralblatt  f.  prakt.  Augenheilk.,"  Dec.  1880,  p.  377. 

3  "Brit.  Med.  Journal,"  1885,  ii.  p.  688. 


CHANGES    IN    THE    OPTIC   NERVE ATROPHY.  113 

The  atrophies  of  the  optic  nerve  which  are  not  associated 
with  spinal  disease  have  been  ascribed  to  various  causes,  the 
influence  of  some  of  which  is  uncertain.  Such  are  :  cold, 
sexual  excess,  menstrual  disturbance,  gastro-intestinal  affec- 
tions, migraine.  With  better  reason  they  have  been  ascribed 
in  rare  instances  to  syphilis,  diabetes,  intermittent  fever,  and 
some  acute  specific  diseases,  and  the  facts  regarding  their 
relation  to  these  will  be  considered  in  Part  II.  In  a  con- 
siderable proportion  of  the  cases  of  primary  atrophy  uncon- 
nected with  spinal  disease,  no  adequate  cause  can  be  ascer- 
tained. Tobacco  and  bisulphide  of  carbon  certainly,  alcohol 
and  lead  possibly,  cause  amblyopia,  and  may  cause  partial 
atrophy,  but  this  is  usually  preceded  by  signs  of  congestion 
or  even  inflammation,  and  there  is  reason  to  believe  that,  in 
the  case  of  tobacco  at  least,  the  lesion  is  a  neuritis  in  the  axis 
of  the  nerve. 

Primary  atrophy  usually  affects  both  eyes,  commonly  one 
much  more,  and  earlier  than,  the  other,  and  in  rare  cases  one 
only. 

Secondary  Atrophy  results  from  lesion  of  the  optic  centres 
or  fibres.  A  cortical  lesion  in  the  brain  about  the  supra- 
marginal  gyrus  (Ferrier)  may,  there  is  reason  to  believe, 
entail  loss  of  sight  of  the  opposite  eye.  This,  although  the 
decussation  at  the  chiasma  is  certainly  in  man  incomplete, 
is  explicable  by  Charcot's  at  present  unproved  theory  of  a 
complemental  decussation  at  the  corpora  quadrigemina.  A 
lesion  outside  the  hinder  part  of  the  optic  thalamus  causes, 
according  to  this  theory,  loss  of  sight  of  the  opposite  eye  and 
of  the  opposite  half  of  the  field  of  vision  of  the  same  side. 
It  is  probable  that  such  damage  does  not  for  a  long  time 
cause  atrophy  of  the  disc.  The  case  from  which  PL  II.  5 
is  taken  makes  it  probable  that  such  atrophy  after  a  time 
does  ensue ;  and  the  same  conclusion  is  suggested  by  a  case 
recorded  by  Bernhardt.1  Lesions  of  one  optic  tract  causing 
bilateral  symmetrical  hemianopia,  seldom  produce  distinct 
ophthalmoscopic  changes.  Some  observers  have  described 
an  ultimate  slight  pallor  of  the  corresponding  halves  of  the 

1  "Berl.  kl.  Wochenschrift,"  1872,  No.  30. 


114  MEDICAL    OPHTHALMOSCOPY. 

discs,  but  this  is  not  often  distinct.  In  one  case  of  long* 
duration,  in  which  the  hemianopia  was  complete  and  per- 
sistent, in  the  course  of  years  the  whole  of  the  disc  of  the 
eye  in  which  the  area  lost  was  on  the  temporal  side  (and 
therefore  greatest),  became  perceptibly  paler  than  the  other, 
the  tint  of  the  two  being  at  first  equal.  A  similar  slight 
pallor  of  the  disc  opposite  to  the  cerebral  lesion  has  been 
noted  by  others  in  cases  of  hemianopia  of  long  duration. 

Pressure  on  the  chiasma  or  nerves  at  the  base  of  the  brain 
is  a  common  cause  of  optic  nerve  atrophy  without  neuritis. 
In  the  case  figured  in  PL  II.  4,  although  there  had  been 
slight  neuritis,  the  atrophy  was  probably  due  to  this  cause. 
The  pressure  may  be  that  of  tumours  growing  from  any  of 
the  adjacent  structures,  exostoses  from  the  bone,  or  aneurisms 
from  the  adjacent  arteries.  It  not  uncommonly  results  from 
internal  hydrocephalus — the  distended  third  ventricle  com- 
presses the  chiasma  directly,  pressing  first  on  the  upper  and 
posterior  aspect,  where,  as  Michel  has  shown,  a  depression 
may  be  thus  produced.1  Meningitis  is  another  cause  which, 
while  commonly  producing  optic  papillitis,  if  extending  to 
the  nerve,  may,  in  rare  cases,  cause  blindness  and  atrophy 
without  intra-ocular  inflammation,  by  pressure  without  in- 
flammatory invasion,  or  it  may  cause  blindness  and  atrophy 
out  of  proportion  to  neuritic  mischief,  and  often  after  the 
inflammation  of  the  papilla  has  subsided.  It  is  probable 
that  the  local  neuritis  in  these  cases  is  often  much  more 
intense  than  is  suggested  by  the  degree  of  intra-ocular 
inflammation.  It  is  said  that  obstruction,  by  embolism  or 
thrombosis,  of  one  middle  meningeal  artery,  which  supplies 
the  dura  mater  around  the  optic  foramen,  may  be  followed 
by  atrophy  of  that  optic  nerve.  Tumours,  exostoses,  and 
meningitis  may  damage  the  nerves  in  front  of  the  chiasma, 
and  so  affect  the  two  eyes  equally,  or  one  to  a  much  greater 
extent  than  the  other,  or  one  exclusively.  The  atrophy  from 
these  causes  is  white  or  grey. 

1  Compression  and  flattening  of  the  chiasma  from  ventricular  distension 
was  noted  by  Cheselden  in  the  last  century.  ("  Phil.  Trans.,"  No.  337, 
p.  281.) 


CHANGES    IN   THE    OPTIC    NERVE ATROPHY.  115 

Damage  to  the  optic  nerves  causing  atrophy  may  also  occur 
in  the  optic  foramen  or  in  the  course  of  the  nerve  through  the 
orbit.  Narrowing  of  the  foramen  by  bony  thickening,  and 
rheumatic  or  syphilitic  or  traumatic  mischief,  producing 
pressure  at  the  back  of  the  orbit,  close  to  the  foramen,  are 
not  rare  causes  of  atrophy.  Blows  on  the  head  commonly 
produce  atrophy  by  direct  injury  to  the  nerve,  but  it  is  pro- 
bable that  they  occasionally  cause,  by  the  effect  of  the  shock,. 
a  gradual  degeneration.  The  ultimate  atrophy  which  results 
from  these  causes  is  usually  more  or  less  distinctly  grey  in 
aspect,  and  the  grey  tint  may  be  as  marked  as  in  the  form  sup- 
posed to  be  characteristic  of  spinal'disease  (see  PL  II.  Fig.  3). 

Mischief  in  the  orbit  may  cause  a  process  of  "  retro-ocular 
neuritis."  This  is  assumed  when  transient  signs  of  congestion 
are  present  in  the  disc,  accompanied  by  constriction  of  vessels 
and  the  development  of  tissue  adjacent  to  them ;  so  that 
ultimately  there  is  considerable  narrowing  of  the  retinal 
vessels,  as  in  the  atrophy  which  is  consecutive  to  intra-ocular 
neuritis.  Sometimes  the  signs  of  neuritis  are  more  marked. 
The  nerve  may  be  thus  damaged  by  the  extension  of  inflam- 
mation to  the  orbit  in  erysipelas  of  the  face. 

Papillitic  or  consecutive  atrophy  results  from  intra-ocular 
neuritis,  as  already  described. 

Retinal  and  Choroiditic  Atrophy. — Lastly,  damage  to  the 
retina  entails  an  atrophy  of  the  optic  nerve,  which  pro- 
gresses, sometimes  slowly,  sometimes  quickly,  but  is  usually 
incomplete.  Now  and  then  atrophy  of  the  optic  nerve  follows 
a  cause  which  seems  to  act  by  giving  a  shock  to  the  retina,, 
that  leaves  no  trace  behind — e.g.,  the  complete  amaurosis,. 
which  may  accompany  the  onset  of  embolism  of  one  branch 
of  the  retinal  artery,  and  is  usually  temporary,  may  some- 
times be  permanent,  even  though  all  the  other  branches  of 
the  retinal  artery  are  previous.  Atrophy  sometimes  follows 
a  blow  on  the  eye,  as  in  a  case  related  by  Laqueur,  in  which 
a  blow  caused  complete  amaurosis  without  visible  changes  in 
the  fundus,  and  simple  atrophy  followed.  Such  cases  are  of 
medical  interest  on  account  of  the  light  they  throw  on  the 
action  of  some  general  causes.  It  is  rarely  that  any  con- 


116  MEDICAL    OPHTHALMOSCOPY. 

siderable  degree  of  atrophy  follows  retinitis.  Commonly,  the 
cause  of  retinal  atrophy  is  obvious  on  ophthalmoscopic 
examination,  and  the  medical  interest  of  this  form  is  sub- 
ordinate to  that  of  the  retinal  change.  After  choroiditis 
the  disc  has  often  a  yellowish-red  tint,  as  already  described 
(p.  110). 

ANATOMICAL  CHANGES. — Atrophy  of  the  optic  nerve  is 
never  confined  to  the  papilla ;  the  changes  are  marked 
throughout  the  whole  length  of  the  nerve,  and  in  primary 
atrophy  are  usually  equally  distributed.  The  size  of  the 
nerve  varies  very  much ;  in  some  forms  of  primary  atrophy  it 
is  markedly  smaller  than  normal,  somewhat  translucent  but 
scarcely  grey,  and  under  the  microscope  may  present  merely 
a  wasting  of  all  the  structures  of  the  nerve,  fibres  and  con- 
nective elements,  with,  especially  in  recent  cases,  products  of 
the  degeneration  of  the  nerve  fibres,  granules  and  globules 
of  fat,  compound  granule  cells,  "  corpora  amylacea,"  and 
other  products  of  degeneration  of  the  nerve  fibres.  The 
position  of  the  latter  may  at  first  be  marked  by  rows  of  fatty 
particles.  In  other  cases  the  nerve  may  be  little  diminished 
in  size,  but  may  present  under  the  microscope  a  great 
increase  in  the  interstitial  connective  tissue,  fibres,  and  cells, 
with  disappearance  of  the  nerve  tubules.  Commonly  the 
change  is  greater  in  the  circumferential  portions  of  the 
nerve  than  in  the  central.1  Occasionally  the  reverse  is 
the  case.  In  atrophy  from  pressure  on  the  nerve,  its  size 
is  usually  greatly  reduced,  and  the  increase  of  connective 
tissue  is  very  considerable. 

In  primary  grey  atrophy  the  nerve  trunk  is  usually  little 
reduced  in  size,  and  is  grey  and  gelatinous  in  appearance. 
Microscopically,  it  presents  an  increase  in  the  connective 
tissue  trabecula3,  and  an  atrophy  of  the  nerve  fibres.  The 
medullary  sheath  first  disappears,  and  afterwards  the  axis 
cylinder.  It  is  said  that  the  nerve  fibres  may  be  reduced  to 
fine  fibrous  threads.  Products  of  myelin  degeneration  may 
be  found  in  the  earlier  stages.  Sometimes  the  change  is 

1  Leber:  "Arch.  f.  Ophth.,"  xiv.  p.  182. 


CHANGES    IN   THE    OPTIC   NERVE ATROPHY.  117 

peculiar  ;  there  developes  round  the  vessels  a  peculiar 
gelatinous-looking  tissue  containing  a  few  nuclei  and  indis- 
tinct concentric  fibrillation.  The  normal  arrangement  of  the 
trabeculae  disappears,  and  a  section  of  the  nerve  (Fig.  51) 
shows  islets  and  tracts  of  this  tissue,  in  the  centre  of  each 
of  which  a  vessel  can  be  traced.  They  may  occupy  at 
least  half  the  area  of  the  section.  Between  them  lie  the 
fasciculi  of  degenerated  nerve  fibres  with  little  increase  in 
their  interstitial  tissue.  In  the  case  figured,  the  atrophy  was 
confined  to  one  optic  nerve,  and  its  cause  was  obscure.  The 
same  histological  condition  may  be  present  in  the  grey 
atrophy  of  locomotor  ataxy.1  In  other  cases  of  grey  de- 
generation (according  to  Leber's  observations)  the  change 
may  be  more  uniformly  distributed  through  the  fasciculi. 
The  degeneration  is  sometimes  found  in  certain  areas  much 
more  intensely  than  elsewhere.  In  a  case  of  locomotor  ataxy 
in  which  sight  was  not  known  to  be  impaired,  I  found  only 
a  great  increase  of  tissue,  consisting  of  nuclei  and  fibres, 
at  the  nodal  points  of  the  trabeculse,  and  a  little  gelatinous- 


FIG.  51. — GREY  ATROPHY  OF  OPTIC  NERVE  :  TRANSVERSE  SECTION, 
MIDWAY  BETWEEN  THE  EYEBALL  AND  THE  OPTIC  FORAMEN. 

The  trunk  of  the  nerve  was  grey,  and  gelatinous  in  aspect,  and  was  not 
diminished  in  size.  The  other  optic  nerve  was  healthy.  The  nerve 
fibres  are  completely  degenerated,  a  granular  tissue  representing  them. 
The  normal  trabeculse  have  disappeared,  and  through  the  section  of  the 
nerve  are  scattered  tracts  and  islets  of  a  slightly  fibrillated,  in  places 
almost  homogeneous,  colloid  looking  tissue.  These  tracts  enclose  vessels 
which  can  be  distinguished,  small  in  size,  and  with  thickened  walls,  in 
the  centre  of  each.  (  x  150.) 

1  Cf.  Perrin  and  Poncet's  "  Atlas" — Atrophy  of  the  Optic  Nerve. 


118  MEDICAL    OPHTHALMOSCOPY. 

looking  tissue  immediately  adjacent  to  the  wall  of  the  vessel. 
It  would  probably  be  unjustifiable  to  assume  that  this  repre- 
sents the  commencement  of  the  process  of  change.  Histology 
has  not  hitherto  afforded  much  information  as  to  the  initial 
lesion  in  these  cases.  It  is  on  the  symptoms  that  the  theory 
of  a  primary  nerve  degeneration  is  based. 

In  cases  of  primary  atrophy  of  the  nerve  the  retina 
is  degenerated  only  in  its  inner  layers — nerve-fibre  and 
ganglion-cell  layer,  as  Yirchow  first  showed.1  The  other 
retinal  elements  may  persist  in  a  perfectly  normal  condition 
even  for  many  years.  Pen-in  and  Poncet  could  find  no 
change,  except  in  the  two  inner  layers,  in  a  case  of  ataxy 
in  which  sight  had  been  lost  for  thirty  years. 

The  degeneration  from  damage  to  the  trunk  of  the  nerve 
ascends  to  the  chiasma,  and  descends  to  the  eye.  It  is  long 
in  passing  the  chiasma,  and,  even  with  complete  atrophy  of 
one  optic  nerve,  the  optic  tracts  are  only  slightly  reduced  in 
size,  that  on  the  side  opposite  the  affected  nerve  being  rather 
smaller  than  the  other,  without  naked-eye  evidence  of  de- 
generation ;  and  I  have  found  that  the  microscopic  changes 
are  nearly  equally  distributed  through  the  two.2  When 
both  optic  nerves  are  degenerated  the  optic  tracts  may  pre- 
sent the  same  condition,  traceable  (as  Tiirck  pointed  out)  as 
far  as,  and  involving,  the  external  corpora  geniculata. 

Consecutive  or  Posf-papittitic  Atrophy.  —  The  microscope 
shows  the  substance  of  the  disc  to  be  occupied  by  nucleated 
connective-tissue  fibres,  among  which,  commonly,  few  or  no 
traces  of  nerve  fibres  are  to  be  discerned.  Often,  however, 
the  nuclei,  by  their  grouping,  indicate  the  position  of  the 
intervals  between  the  fasciculi  of  former  nerve  fibres.  The 
retinal  layers  are  displaced  outwards  (Fig.  21),  an  im- 
portant sign  of  the  preceding  swelling,  and  both  they  and 
the  commencement  of  the  choroid  may  present  some  dis- 
turbance. The  atrophy  of  the  rest  of  the  retina  is  confined 
to  the  inner  layer,  especially  affecting  the  layer  of  nerve 
fibres. 

1  Virchow's  "  Archiv,"  vol.  x.  1856. 

2  "  Centralblatt  f.  die  med.  Wissensch.,"  1878,  No.  31. 


CHANGES    IN   THE    OPTIC   NERVE ATROPHY.  119 

SYMPTOMS. — The  symptom  of  atrophy  is  affection  of  sight 
proportioned  to  the  damage  to  the  nerve  fibres.  The  patient 
becomes  conscious  of  a  cloud  over  objects,  which  increases ; 
of  difficulty  in  seeing  certain  minute  objects,  such  as  small 
print :  and  sometimes  of  a  dark  area  in  some  part  of  the 
field  of  vision.  Examination  shows  a  change  in  sight  in 
three  directions — (1)  diminished  acuity  of  vision  ;  (2)  altera- 
tion in  the  field  of  vision  ;  (3)  altered  perception  of  colours. 

1.  Diminution  in  the  acuity  of  vision   is  invariable   when 
the  atrophy  is  pronounced ;  it  is  almost  always  more  con- 
siderable in  one  eye  than  in  the  other.     In  estimating  it 
care  must  be  taken  to  ascertain  and  correct  any  errors  of 
refraction  and  defects  of  accommodation.     It  may  vary  from 
a  slight  degree  to  complete  loss.     It  is  commonly,  but  not 
always,  proportioned  to  the  degree  of  change  in  the  optic 
nerve  visible  with  the  ophthalmoscope. 

2.  Alteration  in  the  field  of  vision  may  be  of  several  kinds. 
It  is  almost  as  constant  as  the  diminution  in  the  acuity  of 
vision.     The  form  is  commonly  a  limitation  at  the  margin  of 
the  field,  progressing  concentrically  until  only  a  small  central 
area  is  left,  such  as  is  shown  in  Fig.  52.     Such  a  limitation 


TIG.  52. — CONCENTRIC  LIMITATION  OF  LEFT  FIELD  OF  VISION  IN  A  CASE 
OF  ATROPHY  OF  THE  OPTIC  NERVE. 

The  outer  boundary  of  the  figure  is  the  limit  of  the  normal  field.     The  inner 
white  area  is  the  area  of  the  restricted  field. 


120  MEDICAL   OPHTHALMOSCOPY. 

may  progress  much  more  on  one  side  of  the  field  than  on  the 
other,  or  it  may  progress  much  more  in  one  part  of  the  field 
than  in  another,  so  as  to  cause  a  sector-like  defect.  Occa- 
sionally the  diminution  is  limited  to  one-half  of  the  field, 
vertical  or  lateral.  Lastly,  in  some  cases,  the  first  loss  is  a 
central  one,  in  the  middle  of  the  field,  a  "  central  scotoma," 
as  it  has  been  termed.  There  is  often  in  these  cases  dimness 
of  the  peripheral  vision,  without  concentric  narrowing  of  the 
field. 

3.  Colour-Blindness. — In  many  cases  the  perception  of 
colours  is  perverted.  There  are  two  methods  of  testing  colour- 
vision.  If  the  patient  possesses  sufficient  intelligence,  he  may 
be  asked  to  identify  certain  colours.  If  the  patient  is  unintel- 
ligent, the  "  confusion  method"  must  be  adopted,  by  which 
the  colours  which  are  seen  alike  are  ascertained.  The  former 
method,  however,  sometimes  gives  the  more  valuable  in- 
formation. 

Modern  physiological  speculation  suggests  that  there  are 
four  fundamental  colours,  related  in  complementary  pairs,  red 
and  green,  yellow  and  blue.  The  area  of  the  field  of  vision 
in  which  these  colours  are  seen  varies  for  each.  If  coloured 
objects  are  moved  from  the  centre  of  the  field  to  the  peri- 
phery, the  first  simple  colour  to  be  unperceived  is  green,  the 
next  red,  and  yellow  and  blue  are  lost  near  the  edge  of  the 
field  for  white.  Commonly  yellow  is  lost  before  blue,  but 
sometimes  the  latter  is  lost  first.  If  the  distance  at  which 
each  colour  ceases  to  be  distinguished  in  various  parts  of  the 
field  is  marked  upon  a  chart,  we  have  a  series  of  concentric 
lines  such  as  shown  in  Fig.  53,  in  which  the  most  internal 
is  the  field  for  green,  and  the  most  external  the  field  for 
yellow,  the  outer  circle  being  that  for  white.  The  amount 
of  light  influences  very  much  the  area  of  the  fields,  and 
those  shown  in  Fig.  53  were  taken  upon  a  dull  day,  and 
present  the  minimum  normal  fields.  Fig.  54  shows  the 
respective  fields  of  larger  size,  and  the  blue  field  the  most 
extensive.  Compound  colours  are  lost  sooner  than  their 
constituents,  and  the  inner  circle  in  Fig.  54  represents  the 
field  for  violet,  which  is  even  smaller  than  that  for  green. 


CHANGES    IN   THE    OPTIC    NERVE — ATROPHY. 


121 


Commonly,  in  atrophy  of  the  nerve,  the  first  defect  is  for 
green  and  red,  and  blue  and  yellow  are  lost  subsequently. 
The  order  of  affection  is  commonly  that  in  which  the  fields 
are  arranged  on  the  retina.  The  simple  colour  first  lost  in 
passing  from  the  centre  to  the  periphery  of  the  retina  is  that 
first  lost  in  atrophy,  green  ;  and  the  last  to  be  lost  is  blue  or 
yellow.1  Thus  a  girl,  lately  under  observation,  suffering 
from  disseminated  sclerosis  and  commencing  grey  atrophy, 
recognized,  with  the  affected  eye,  every  colour  except  green, 
which  she  called  red  or  brown.  In  another  case  there  was 
entire  loss  of  perception  for  green  only.  Occasionally  red 
appears  to  be  lost  first.  A  patient  with  ataxy  and  advanced 


FIG.  53. — A  REPETITION  OF  FIG.  39.  DIAGRAM  SHOWING  THE  FIELDS  OF 
COLOUR- VISION  IN  A  NORMAL  EMMETROPIC  EYE  ON  A  DULL  DAY. 

The  fields  are  each  rather  smaller  than  on  a  bright  day.  The  asterisk  indi- 
cates the  fixing  point,  the  black  dot  the  position  of  the  blind  spot. 
(Usually  the  blue  field  is  larger  than  the  yellow.) 

1  It  is  doubtful  whether  this  is  true  of  violet,  which  is  a  compound  colour. 
In  some  cases  (it  is  said  in  hysterical  amblyopia — Charcot)  violet  is  first  lost. 
Sometimes,  however,  it  persists  to  the  last.  Abadie  suggests,  on  the  theory 
that  the  same  fibres  conduct  all  colour  impressions,  that  the  first  degenerative 
change  in  the  fibre  interferes  with  its  power  of  conducting  the  special  impres- 
sion excited  by  green  rays,  and  the  further  changes  abolish  its  power  of 
conducting  the  impressions  excited  by  other  rays,  in  the  order  above  given. 
("Ann.  d'Oculistique,"  1878.) 


122 


MEDICAL    OPHTHALMOSCOPY. 


atrophy  (under  the  care  of  Dr.  Buzzard)  stated  that  the  first 
loss  of  the  sense  of  colour  of  which  he  was  conscious,  was 
ihat  he  could  see  no  colour  in  a  scarlet  geranium.  Bed 
gravel  looked  grey  to  him.  Soon  afterwards  the  grass  also 
looked  grey,  and  he  could  not,  at  a  little  distance,  distinguish 
it  from  the  gravel.  When  examined,  violet  alone  was  seen 
as  a  colour,  he  said  it  looked  blue.  A  medium  blue  was  seen 
as  white.  Cases  have  also  been  met  with  by  UhthofC,  Leber, 
and  Treitel  in  the  stage  in  which  perception  of  red  was  lost 
and  of  green  was  preserved.  The  loss  of  perception  of  colour 
is  often  rather  a  colour  amblyopia  than  blindness,  large  pieces 
of  colour  may  be  seen  when  small  spots  are  not.  The 
fields  for  colour-vision  may  present  alterations  similar  to 
those  already  described  as  occurring  in  the  field  for  white. 
Abadie1  has  lately  attributed  especial,  and  certainly  undue, 


FIG.  54. — FIELDS  OF  VISION  FOB  DIFFERENT  COLOURS. 

(After  Snellen  and  Landolt.) 

w,  white  ;    B,   blue  ;  Y,  yellow  ;   R,  red  ;  G,  green ;    v,  violet.     These  are 
probably  the  maximum  normal  fields  for  each  colour. 

1<(Ann.   d'Oculistique,"   1878,   and   Lebris,   "These  sur  les    Differentes 
Jormes  de  1'Atrophie  de  la  Nerf  Optique."     Paris,  1878. 


CHANGES   IN    THE    OPTIC   NERVE ATROPHY.  123 

importance  to  the  loss  of  colour- vision  as  a  supposed  distinc- 
tion of  the  parenchymatous  from  the  interstitial  forms.  It 
is  probably  of  little  significance  as  regards  these  forms.  The 
most  characteristic  loss  usually  attends  interstitial  processes. 

Relation  of  Symptoms  to  Form  of  Atrophy. — It  was  suggested 
by  Leber  that  the  central  fibres  of  the  optic  nerve,  on  their 
emergence,  probably  occupy  the  most  superficial  of  the 
nerve-fibre  layers  of  the  retina,  and  have  the  longest  course, 
while  the  fibres  in  the  circumference  of  the  nerve  lying 
deepest  in  the  retina  end  soonest.  On  this  theory  a  con- 
centric limitation  of  the  field  was  ascribed  to  an  affection 
of  the  axial  fibres  of  the  nerve,  the  central  scotoma  to 
that  of  the  circumferential  fibres.  Forster,  however,  reversed 
this  theory,  ascribing  the  central  scotoma  to  an  affection  of 
the  axial  fibres  of  the  nerve.  Recent  investigations  have 
conclusively  proved  that  Forster's  view  is  nearer  the  truth. 
Two  cases  have  been  published,  one  by  Samelsohn,1  the  other 
by  Nettleship  and  Edmunds,2  in  each  of  which  a  central 
scotoma  was  found  to  be  due  to  the  degeneration  of  a  tract 
of  fibres,  which  at  the  back  of  the  orbit  occupied  the  axis  of 
the  nerve,  but  in  front  of  the  entrance  of  the  central  artery 
lay  on  the  outer  side.  Thus  the  hypothesis  of  Forster  that 
a  central  scotoma  might  be  an  indication  of  "  axial  neuritis  "3 
is  verified.  Moreover,  the  converse  verification  has  been 
afforded  by  a  case  recorded  by  Wilbrand  and  Biswanger,4 
who  found  that  a  peripheral  defect  in  the  field  of  vision  was 
due  to  an  affection  of  the  circumferential  portion  of  the  optic 
nerve. 

Concentric  limitation  of  the  field  is  very  common  in  all 
forms  of  atrophy.  In  the  spinal  and  simple  progressive  forms 
it  most  frequently  begins  on  the  outer  side,  but  may  com- 
mence on  the  inner  side  above  or  below.  The  acuity  of 
vision  may  fail  at  the  same  time,  or  may  remain  normal  until 

1  "Centralbl.  f.  med.  Wissensch.,"  1880,  p.  418. 

2  "  Trans.  Ophthalmological  Society,"  vol.  i.  1881,  p.  124. 

3  See  Wilbrand  :  "  Klin.  Monatsbl.  f.  Augenheilk.,"  Dec.  1878 

4  "  Centralblatt  f.  med.  Wissensch.,"  1879,  p.  923,  from  the  "  Breslauer 
Artzl.  Zeitschrift,"  1879. 


124 


MEDICAL    OPHTHALMOSCOPY. 


the  field  is  reduced  to  a  very  small  area.  "When  acuity  is 
preserved,  if  the  limitation  is  regular  and  sharp,  central 
colour-vision  may  be  normal,  but  the  fields  are  reduced  in 
area,  preserving  their  normal  relation  to  the  field  for  white. 
When  the  limitation,  although  sharply  defined,  is  irregular, 
colour- vision  is  usually  much  impaired  (Nettleship1).  If,  with 
considerable  concentric  narrowing,  acuity  of  vision  has  failed 
greatly,  colour- vision  is  usually  much  impaired  or  lost. 

A  loss  of  one-half  of  the  field  of  vision  (apart  from  cere- 
bral hemianopia)  is  met  with  chiefly  in  secondary  atrophy, 
especially  when  the  cause  is  pressure  on  the  chiasma,  the 
temporal  halves  of  the  fields  being  then  usually  lost 
(see  p.  72).  But  a  loss  of  one-half  of  the  field  is  met  with 
in  rare  cases  of  primary  atrophy.  Thus  in  a  case  of  grey 
atrophy  associated  with  locomotor  ataxy,  the  patient  averred 
that  he  rapidly  lost  vision  outwards  in  each  eye.  When  he 
came  under  observation  there  was  entire  loss  of  the  right 
field  and  loss  of  the  temporal  half  of  the  left  field,  the  loss 
including  the  fixing  point  (Figs.  55  and  56).  Precisely  the 
same  affection  of  sight  was  present  in  a  case  of  tabetic 
atrophy  described  by  Treitel.2 


R  L 

FIG.  55.  FIG.  56. 

FIELDS  OF  VISION  IN  A  CASE  OF  LOCOMOTOR  ATAXY  WITH  GKEY 

ATROPHY. 

The  shading  indicates  loss.      The  outer  dotted  line  indicates  the  field  for 
blue,  the  inner  that  for  yellow. 

1  "  British  Med.  Journal,"  1880,  ii.  779. 

2  "  Arch.  f.  Ophth.  "  vol.  xxv.  1879,  p.  61. 


CHANGES   IN    THE    OPTIC   XERVE ATROPHY. 


125 


Sector-like  defects  in  the  field  are  met  with  in  secondary 
atrophy,  especially  in  cases  of  injury  to  the  trunk  of 
the  nerve  at  the  posterior  part  of  the  orbit.  They  also  occa- 
sionally occur  in  simple  progressive  atrophy  and  in  spinal 
atrophy.  A  well-marked  instance  of  this  condition  in  spinal 
atrophy  is  shown  in  Figs.  57  and  58.  The  patient  was  in  the 
earliest  stage  of  locomotor  ataxy.  The  optic  discs  were 
grey  and  the  vessels  small ;  vision  was  E.  TV,  L.  ~. 

Sector-like  defects  in  primary  atrophy  may  be,  as  in  this 
case,  symmetrical,  but  they  are  sometimes  unilateral,  as  in  a 
tabetic  atrophy  recorded  by  Uhthoff,1  where  in  one  eye  there 
was  a  defect  of  the  upper  and  inner  quadrant,  and  in  two 
cases  described  by  Treitel  there  was  a  defect  in  the  inner 
and  lower  part  in  the  right  eye,  as  in  the  case  figured. 

Central  scotomata  are  usually  transversely  oval,  extending 
from  the  blind  point  to  the  fixing  point,  sometimes  involving 
both,  sometimes  one  only.  It  is  uncertain  at  which  point 
they  usually  commence.  The  periphery  of  the  field  is  usually 
normal,  but  it  may  probably  sometimes  be  restricted.  There 
is  always  a  loss  of  colour-vision,  and  this  may  be  greater 
and  occur  earlier  than  that  for  white.  Red  and  green  are 
first,  and  may  be  only  lost.  Central  scotomata  for  red  are 


SECTOR-LIKE  DEFECT  IN  FIELDS  OF  VISION  IN  A  CASE  OF 
SPINAL  ATROPHY. 

The  shading  represents  amblyopia,  the  black  loss.  The  dotted  line  shows 
the  boundary  of  the  field  for  red.  Where  it  is  absent  the  field  ceased  so 
gradually  that  its  limit  could  not  be  ascertained. 

1  "Arch.  f.  Ophth.,"  vol.  xxvi.  1880,  pt.  1,  p.  277. 


126  MEDICAL   OPHTHALMOSCOPY. 

shown  in  Figs.  59,  60,  and  61.  They  are  met  with  in  cases  of 
axial  neuritis  and  degeneration,  and  especially  in  cases  of 
amblyopia  from  tobacco.  That  the  latter  depends  on  the  same 


LEFT 

FIG.  59 — DIAGRAM  OF  THE  LEFT  FIELD  OF  VISION  FOR  RED  IN  A  CASE  OF 
TOBACCO  AMBLYOPIA. 

The  outer  line  is  the  boundary  of  the  normal  field  for  white.  The  boundary 
of  the  outer  shaded  area  is  the  minimum  normal  field  for  red.  Red 
could,  however,  be  seen  only  in  the  inner  white  area,  and  it  could  not 
be  seen  in  the  central  shaded  area  around  the  fixing  point  (*).  The 
black  dot  indicates  the  position  of  the  blind  spot.  (For  the  chart  from 
which  this  diagram  was  prepared  I  am  indebted  to  Air.  Nettleship. ) 


FIG.  60.  FIG.  61. 

CENTRAL  SCOTOMATA  FOR  RED,  EMBRACING  FIXATION  POINT  AND 

BLIND  SPOT. 

No  loss  for  white  but  considerable  amblyopia  (16  Jager).  The  patient  had 
smoked  half  an-ounce  of  shag  daily.  The  dotted  line  represents  the 
peripheral  boundary  of  the  field  for  red.  (Nettleship.) 


CHANGES   IN    THE    OPTIC   NERVE ATROPHY. 


127 


pathological  condition  (axial  neuritis)  is  probable,  both  from 
the  character  of  the  affection  of  vision  and  from  the  fact  that 
signs  of  congestion  or  slight  neuritis  are  often  observed  at 
the  papilla.  A  central  scotoma  is  occasionally  met  with 
in  consecutive  (papillitic)  atrophy.  It  may  occur  also  in  the 
atrophy  which  succeeds  loss  of  blood,  and  is  probably  pro- 
duced by  neuritis.  Central  loss  is  occasionally  met  with  in 
simple  progressive  atrophy,  but  in  spinal  atrophies  it  is 
extremely  rare — has  been  said,  indeed,  never  to  occur.  In 
a  case  under  my  care,  however,  there  was  central  scotoma 
(Figs.  62  and  63),  associated  with  the  symptoms  of  lateral 
and  posterior  sclerosis  of  the  cord,  and  some  cerebral  degene- 
ration ;  the  existence  of  slight  papillitis  makes  it  probable 
that  axial  neuritis  existed,  and,  since  the  patient  smoked  a 
little,  the  influence  of  tobacco  cannot  be  entirely  excluded. 

Peripheral  areas  of  vision,  with  general  loss,  are  met  with 
only  in  cases  of  orbital  inflammation  or  in  consecutive 
(papillitic)  atrophy.  The  changes  in  the  latter  are  often 
very  irregular.  There  may  be  general  concentric  limitation 
of  the  field,  or,  less  commonly,  a  central  loss,  rarely  sharply 
defined.  Failure  of  colour-vision  is  very  frequent,  but  is 
often  less  regular  in  order  than  in  primary  atrophy  (see 
"Neuritis,"  p.  71).  The  colour  fields  may  present  very 


CENTRAL  SCOTOMATA  IN  A  CASE  OF  DEGENERATION  OF  THE 
SPINAL  CORD. 

There  was  a  rather  larger  central  loss  for  red  and  green,  but  the  peripheral 
arublyopia  for  these  colours  was  also  considerable. 


128  MEDICAL   OPHTHALMOSCOPY. 

irregular  defects,  as  in  Figs.  64  to  66,  representing  the  fields 
for  white,  red,  and  green  in  a  case  of  post-neuritic  atrophy. 
That  for  yellow  and  blue  was  normal,  except  for  a  limita- 
tion below,  and  to  the  inner  side,  corresponding  to  the  field 
for  white.  They  were  taken  nine  months  after  the  subsi- 
dence of  neuritis,  when  acuity  had  improved  to  %.  Uhthoff 
once  met  with  a  central  scotoma  for  blue  only. 

As  a  rule  there  is  more  or  less  correspondence  between 
the  pallor  of  the  disc  and  the  failure  of  sight.  When  it  is 
considered,  however,  that  the  tint  of  the  disc  depends  on  its 
blood-vessels,  and  the  amount  of  vision  on  the  integrity  of 
the  nerve  fibres  which  merely  pass  through  the  disc,  and  have 
a  long  course  on  each  side  of  it,  it  is  not  surprising  to  find 
that  the  correspondence  between  the  tint  and  vision  is  not 
always  close.  A  very  remarkable  case  has  been  recorded  by 
Krenchel,1  in  which  the  optic  discs  of  a  boy  became  "  as 
white  as  porcelain,"  although  vision  was  normal.  After  some 
time,  however,  sight  failed  with  great  rapidity. 

DIAGNOSIS. — The  diagnosis  of  simple  atrophy  of  the  optic 
nerve  rests  especially  on  the  change  of  colour,  and  the  chief 
difficulty  in  the  diagnosis  is  due  to  the  degree  of  pallor 
sometimes  seen  as  a  physiological  condition.  The  existence 
of  amblyopia,  otherwise  unexplained,  is  strong  evidence  that 
the  pallor  is  pathological.  The  pallor  of  the  temporal  half 
of  the  normal  disc  may  be  great  when  the  physiological  cup 
is  large,  and,  as  already  stated,  may  easily  be  mistaken  for 


w.  R.  G. 

FIG.  64.  FIG.  65.  FIG.  66. 

FIELDS  OF  VISION  FOR  WHITE,  RED  AND  GKEEN  IN  A  CASE  OF 
PAPILLITIC  ATROPHY. 

Y '  Hospitals  Tklende,"  1878,  quoted  in  Virchow's  Jahrnsbericht,"  1878, 
vol.  ii.  p.  474. 


CHANGES    IN    THE    OPTIC    NERVE ATROPHY.  129 

atrophy.  It  is  certain  that  many  normal  cases  have  been 
described  as  "  atrophy  of  the  temporal  half  of  the  disc."  It 
is  doubtful  whether  an  atrophy  is  ever,  except  in  toxic  cases, 
confined  to  the  temporal  half  of  the  disc,  in  which,  ordi- 
narily, the  nerve  fibres  are  very  few.  Although  it  is  true 
that  a  slight  degree  of  atrophy  may  produce  the  most 
distinct  changes  in  this  half  of  the  disc,  yet  some  pallor  is 
always  to  be  recognized,  in  such  cases,  in  the  nasal  as  well 
as  in  the  temporal  half.  The  diagnosis  of  the  congestive 
variety  of  atrophy  presents  greater  difficulties,  but  rests  on 
the  uniform  distribution  of  the  redness,  its  soft,  velvety 
surface,  the  slight  blurring  of  the  edge  of  the  disc,  in  com- 
bination with  defective  vision. 

Beginners  sometimes  mistake  the  white  crescent  of  "  pos- 
terior staphyloma  "  for  part  of  the  disc,  and  thus  think  the 
outer  part  of  the  disc,  the  colour  of  which  is  of  such  special 
significance,  is  white.  Occasionally,  especially  in  myopic 
eyes,  the  choroid  presents  a  zone  of  atrophy,  soft  edged, 
around  the  entire  circumference  of  the  disc,  which  then  has 
an  unusual  and  puzzling  appearance.  In  both  these  cases, 
however,  attention  to  the  fact  that  the  pale  zone  encloses  a 
well-coloured  disc  will  prevent  mistake  as  to  its  real  nature. 

The  excavation  which  accompanies  the  pallor  is  of 
secondary  diagnostic  importance,  and  it  is  not  often  that 
a  difficulty  in  distinguishing  atrophy  from  other  forms 
of  excavation  arises.  It  may,  however,  occur.  A  large 
physiological  cup  may  be  bounded  by  a  narrow  rim  of 
deeply- coloured  disc,  the  boundary  of  which  from  the 
choroid  may  not  be  apparent  on  a  cursory  inspection  by 
.the  indirect  method  of  examination,  and  the  large,  deep, 
sometimes  grey,  cup  may  be  mistaken  for  the  disc.  A 
careful  inspection  of  the  edge  will  prevent  doubt,  and  the 
examination  by  the  direct  method  at  once  shows  the  source 
of  the  error. 

The  excavation  of  atrophy  commences  at  the  sclerotic  ring, 
and  this  is  a  character  also  of  another  form  of  excavation, 
namely,  that  of  glaucoma.  But  the  depth  of  the  glauco- 
matous  cup,  its  vertical  sides,  and  the  course  of  the  vessels 

K 


130  MEDICAL   OPHTHALMOSCOPY. 

over  the  edge,  and  their  subsequent  disappearance,  are 
diagnostic,  especially  since  the  pain  which  is  so  common 
(though  not  invariable)  in  glaucoma  is  never  present  in 
simple  atrophy. 

PROGNOSIS.  — The  prognosis  of  atrophy  of  the  optic  nerve, 
on  whatever  cause  it  depends,  is  always  unfavourable  in  pro- 
portion to  the  actual  destruction  of  fibres  which  has,  taken 
place,  and  to  the  extent  to  which  the  causes  influencing  the 
disease  are  beyond  control.  Simple  primary  atrophy  is 
usually  due  to  a  tendency  to  degeneration  beyond  all  influ- 
ence, and  the  prognosis  is,  in  this  form,  the  least  favourable. 
This  is  especially  the  case  when  the  atrophy  is  associated 
with  symptoms  of  degeneration  elsewhere  in  the  nervous 
system.  Secondary  degeneration  is  often  the  consequence 
of  the  operation  of  causes  which  may  pass  away,  and  the 
prognosis  is  less  uniformly  grave  than  in  primary  degene- 
ration. It  must,  however,  always  be  somewhat  uncertain, 
since  it  is  often  very  difficult  to  form  an  accurate  opinion  of 
the  nature  of  the  process  causing  the  damage  to  the  nerve, 
on  which  the  secondary  degeneration  depends.  In  the 
congestive  form  the  prognosis  is  perhaps  rather  better  than 
in  the  other  forms.  In  the  atrophy  which  is  consecutive  to 
intra-ocular  neuritis,  we  are  able  to  form  a  more  accurate 
estimate  of  the  course  of  the  affection  by  the  fact  that,  as 
long  as  the  new  tissue  of  the  disc  goes  on  contracting,  the 
damage  to  the  nerve  fibres  increases,  and  the  sight  will  go  on 
failing.  If  sight  is  lost  from  such  contraction  some  time 
before  it  reaches  its  maximum,  the  prognosis  is  very  grave. 
If,  however,  the  loss  of  sight  is  incomplete,  or  only  becomes- 
complete  when  the  subsidence  is  nearly  over,  some  sub- 
sequent slow  improvement  may  be  hoped  for,  and  this  may, 
in  less  severe  cases,  be  very  great.  In  a  case  which  I  have 
published  elsewhere,1  for  example,  probably  of  tumour  in  the 
middle  lobe  of  the  cerebellum,  there  was  at  first  double  optic 
neuritis,  with  great  swelling.  On  the  subsidence  of  the  optic 
neuritis,  six  months  later,  it  had  diminished  in  both  eyes  to 
1  "Trans.  Ophth.  Soc.,"  i.  117. 


CHANGES    IN    THE    OPTIC    NERVE  — ATROPHY.  131 

Y1^-.  After  this  the  disc  atrophied,  but  at  the  same  time 
vision  improved,  until,  fifteen  months  after  the  first  obser- 
vation, it  had  risen  to  f ,  and  the  pupils,  which  had  shown 
formerly  no  reaction  to  light,  again  acted  mormally.  Under 
all  circumstances,  it  is  unhappily  true  that  a  disc  which  has 
lost  all  its  normal  tint  never  regains  its  vascularity,  and 
useful  vision  is  scarcely  ever  recovered. 

Some  prognostic  indications  may  also  be  drawn  from  the 
form  of  the  affection  of  sight.  The  gravest,  that  which 
indicates  not  merely  damage,  but  destruction  of  nerve  fibres, 
is  considerable  contraction  in  the  field  of  vision.  In  propor- 
tion as  this  is  extensive  the  prognosis  is  grave.  Lessened 
acuity  of  vision  is  of  less  serious  prognostic  significance. 
The  change  in  colour- vision  is  least  grave  when  this  depends 
on  a  toxic  cause,  or  on  neuritis ;  but  is  most  grave  when  it 
is  due  to  a  primary  degeneration,  and  occurs  early.  Central 
scotomata  rarely  go  on  to  complete  atrophy. 

Although  the  chance  of  restoration  of  useful  vision  in  pro- 
nounced atrophy  is  small,  in  some  cases  the  progress  of  the 
disease  may  be  arrested,  for  a  time  or  permanently,  and  even 
improvement  obtained,  occasionally  considerable  in  degree. 

TREATMENT. — The  treatment  of  optic  atrophy  is  essentially 
that  of  the  general  condition  on  which  it  depends — toxic 
influences ;  excesses,  sexual,  physical,  mental ;  cerebral  and 
spinal  disease,  the  "  neuropathic  constitution,"  &c.  The 
treatment  of  many  forms  of  atrophy  which  are  due  to  an 
isolated  ocular  condition  is  beyond  the  scope  of  the  present 
work.  Cerebral  processes  may  be  to  some  extent  influenced 
by  treatment.  Although  it  is  not  certain  that  there  is  such 
a  thing  as  an  actual  syphilitic  atrophy,  yet  atrophy  does  often 
result  from  syphilitic  intra-cranial  disease,  and  may  greatly 
improve  with  the  removal,  by  appropriate  tieatment,  of  its 
cause.  Scrofulous  brain  disease,  again,  may  often  be  bene- 
ficially influenced,  and  its  effects  greatly  lessened.  In  other 
cases  counter-irritation,  local  depletion,  purgation,  and  the 
like,  effect  good. 

In  cases  of  primary  atrophy,  which  are  the  result  of  a 


132  MEDICAL   OPHTHALMOSCOPY. 

neuropathic  tendency,  the  treatment  has  to  be  directed  to  the 
general  health,  and  nervine  tonics  are  the  chief  agents  to  be 
employed.  Nitrate  of  silver  has  been  found  useful  in  some 
cases :  in  others  phosphorus,  in  others  strychnia.  The  hypo- 
dermic injection  of  strychnia,  so  useful  in  amblyopia  without 
ophthalmoscopic  signs  of  atrophy,  is  of  little  service  where 
these  are  present.  Quinine  and  iron  are  in  some  cases  very 
useful. 

When  perception  of  light  is  not  entirely  lost,  the  retina 
may  be  readily  stirmilated  by  an  interrupted  voltaic  current, 
so  as  to  give  rise  to  a  sensation  of  light,  and  this  has  suggested 
repeated  stimulation  of  this  character  as  a  means  of  treating 
optic  nerve  atrophy.  Some  improvement,  following  treat- 
ment with  the  continuous  current,  has  been  observed  by 
Pye-Smith l  and  Gunn 2  in  a  few  of  their  cases ;  the  ex- 
perience of  others  has  also  been  generally  unfavourable. 
I  have  tried  it  in  many  cases,  but  without  results  which 
could  reasonably  be  ascribed  to  the  treatment. 

THE  EETINA. 

Apart  from  the  vessels  and  the  optic  disc,  the  changes  in 
the  retina  which  are  of  medical  importance,  are  those  which 
are  special  to  certain  general  diseases,  such  as  syphilis,  albu- 
minuria,  leucocythaemia,  pernicious  anaemia,  and  the  like. 
They  will  be  described  in  detail  in  Part  II.,  in  the  sections 
on  the  ophthalmoscopic  changes  in  the  several  diseases.  The 
only  common  feature  which  these  morbid  states  possess,  is  the 
development  in  the  retina  of  haemorrhages  and  white  spots 
and  patches.  The  haemorrhages,  their  characters  and  signi- 
ficance, have  been  already  described  (p.  25).  It  may  be 
convenient  briefly  to  describe  the  forms  of  white  patches 
which  the  retina  may  present  under  pathological  conditions. 

A  diffuse,  slight  opacity  of  the  retina  may  be  due  to  the 
derangement  of  its  normal  structure,  resulting  from  the 
effusion  of  serum  among  the  structures  which  compose  it. 
Such  diffuse  opacity  occurs  in  embolism,  neuritis,  and 

1  "  British  Med.  Journal,"  May  18,  1872. 

2  "Ophtk.  Hosp.  Rep.,"  vol.  x.  pt.  2,  June,  1881,  p.  161. 


CHANGES    IN    THE    RETINA. 


183 


albuminuric  retinitis,  but  in  all,  and  especially  in  the  latter, 
it  is  usually  associated  with  structural  changes.  Circum- 
scribed opaque  white  spots  are  due  to  change  other  than 
that  of  simple  oedema,  and  commonly  of  four  varieties  :  (1) 
Fibrinous  exudations  which  undergo  coagulation ;  (2)  the 
accumulation  of  corpuscles,  similar  in  appearance  to  those  of 
the  nuclear  layer,  and  also  to  the  white  corpuscles  of  the 
blood,  so  that  it  is  doubtful  from  which  source  they  are  de- 
rived ;  (3)  fatty  degeneration  of  the  retinal  elements,  perhaps 
also  in  part  of  fibrine  from  the  serum  effused  in  simple 
oedema,  and  of  the  remains  of  blood  clot ;  (4)  a  fibroid  change, 
a  process  of  "  sclerosis  "  of  the  retinal  elements  is  described  as 
an  occasional  cause  of  a  white  spot,  but  is  more  frequently 
confined  to  the  perivascular  tissues  and  vessel- wall. 

These  conditions  are  frequently  combined.  The  fatty 
degeneration  may  exist  alone,  as  the  sole  cause  of  a  white 
spot.  Corpuscular  accumulation  usually  involves  a  good 
deal  of  fatty  degeneration  in  the  cells  and  in  the  disturbed 
retinal  elements.  Sclerosis  of  the  retinal  structures  is  also 
in  most  cases  associated  with  fatty  degeneration. 

It  is  often  impossible  to  say,  from  the  ophthalmoscopic 
appearance,  on  what  change  the  white  spot  depends.  Minute 
granular-looking  spots,  brilliantly  white,  are  commonly  due 
to  fatty  degeneration  of  retinal  structures  or  of  leucocytes,  &c. 
Larger  white  spots,  if  soft  edged,  are  commonly  effused  fibrine 
or  accumulations  of  leucocytes,  especially  if  situated  beneath 
the  nerve-fibre  layer.  Fatty  degeneration  of  the  retinal 
structures  is,  however,  commonly  associated.  White  spots  in 
the  superficial  layer  of  the  retina,  most  common  in  Bright's 
disease,  are  due  usually  to  degeneration  of  the  nerve  fibres. 

Growths  in  the  retina  sometimes  occur  in  cases  in  which  there 
are  other  growths  elsewhere.  The  disc  shown  in  PI.  III.  4 
was  from  a  boy  who  had  cerebral  tubercles,  and  whose  other 
eye  was  the  seat  of  a  tubercular  growth  behind  the  retina. 

The  occurrence  of  miliary  tubercles  of  the  retina  has  been 
suspected  by  many  observers.  White  spots  are  sometimes 
seen  adjacent  to  the  disc  in  cases  of  tubercular  meningitis, 
and  such  a  spot  in  one  case  I  found  to  be  made  up  of 


134  MEDICAL    OPHTHALMOSCOPY. 

lymphoid  cells  like  those  of  the  nuclear  layers  in  which  it 
was  situated.  Bouchut  has  seen  white  spots  at  a  distance 
from  the  disc,  near  the  vessels.  Microscopically,  he  always 
found  them  to  contain  only  products  of  fatty  degeneration. 
He  suspected  them  to  be  caseous  tubercles,  but  there  was 
no  direct  evidence  that  this  was  their  nature  (see  Part  II.). 

Since  the  white  spots  in  the  retina  which  have  been  de- 
scribed, are  present  in  many  forms  of  retinal  disease  which 
occur  secondarily  to,  and  are  significant  of,  general  diseases, 
it  is  of  great  importance  to  distinguish  them  from  other 
appearances  which  have  a  different  significance. 

First,  it  is  necessary  to  distinguish  whether  the  white  spot 
is  in  the  retina  or  in  the  choroid.  Most  choroidal  white  spots 
are  due  to  atrophy  of  the  choroid,  and  their  distinction  is  easy. 
The  atrophy  of  the  choroidal  pigment  permits  the  white 
sclerotic  to  shine  through ;  some  choroidal  vessels  may  have 
escaped  destruction  and  course  across  the  white  patch ;  its 
edge  is  always  more  or  less  irregular,  and  usually  much  pig- 
mented ;  or  the  choroid  may  exhibit  adjacent  slighter  dis- 
turbance. It  is  easy  to  recognize  by  the  "  parallactic  test " 
(also  in  the  direct  method  by  attention  to  the  time  required 
for  the  necessary  change  of  accommodation) ,  that  the  exposed 
sclerotic  is  some  distance  behind  any  retinal  vessels  which 
pass  in  front  of  it.  Occasionally,  however,  a  white  spot  in 
the  choroid  is  due  to  a  recent  formation,  an  inflammatory 
"  exudation,"  or  a  growth  such  as  tubercle.  This  is  pro- 
minent, and  may  be  difficult  to  distinguish  from  a  white 
spot  due  to  change  in  the  nuclear  layers  of  the  retina.  In 
some  cases  a  little  pigmentary  disturbance  in  the  neighbour- 
hood may  be  seen ;  in  others  the  white  surface  is  distinctly 
so  far  behind  the  retinal  vessels  as  to  be  obviously  at  the  cho- 
roidal level.  If  sufficiently  prominent  to  disturb  the  course 
of  the  retinal  vessels,  the  prominence  may  be  recognized  and 
seen  to  be  considerable  in  degree.  In  other  cases,  the  con- 
ditions of  origin  of  the  spot  may  assist  the  diagnosis.  It 
must  be  remembered  that  large  choroidal  exudations  may 
cause  opacity  of  the  overlying  retina. 

White  spots  due  to  the  persistence  of  the  white  substance 


CHANGES    IN   THE    CHOROI1).  135 

of  the  retinal  nerve  fibres,  or  to  connective  tissue  at  the  back 
of  the  vitreous,  may  be  mistaken  for  new  formations  in  the 
retina.  They  have  been  already  spoken  of.  Pigmentary  de- 
posits in  the  retina  may  be  left  after  extravasation  of  blood, 
but  such  are  always  small.  More  extensive  pigmentation  is 
commonly  the  result  of  the  accumulation  in  the  retina  of 
its  disturbed  pigment,  and  is  a  consequence  of  choroido- 
retinitis,  or  it  is  a  result  of  the  so-called  retinitis  pigmentosa. 
Retinitis  pigmentosa  appears  to  have  some  obscure  con- 
nection with  morbid  states  of  the  nervous  system.  It  occurs, 
as  Liebreich  first  pointed  out,  very  frequently  in  the  offspring 
of  marriages  of  consanguinity.  It  has  been  thought  to  be  con- 
nected with  inherited  syphilis,  but  the  evidence  on  the  subject 
scarcely  supports  the  theory.  It  often  occurs,  however,  in 
families  in  which  there  is  a  history  of  nervous  disease.  This 
is  well  illustrated  by  three  out  of  four  cases  of  the  disease 
narrated  by  Mr.  Nettleship.1  Of  the  first  patient,  two  cousins 
were  epileptic  and  two  insane.  Of  the  second,  the  grandfather 
and  great  aunt  were  insane,  and  an  aunt  half  imbecile,  and 
a  brother  paraplegic.  Of  the  third  patient,  the  mother  was 
epileptic,  and  probably  also  suffered  from  retinitis  pigmentosa. 

THE  CHOBOLD. 

Choroidal  changes,  like  those  of  the  retina,  are  for-  the 
most  part  the  result  of  special  diseases,  and  their  characters 
will  be  described  in  greater  detail  in  Part  II.  Haemorrhages 
are  rarely  seen,  although  their  consequences  are  sometimes 
met  with.  The  common  changes  consist  in  white  spots  and 
the  disturbance  of  the  choroidal  pigment,  which  so  constantly 
results  from  any  changes  in  its  structure.  The  white  spots 
are  either  new  formations  or  patches  of  atrophy.  The  distinc- 
tions between  them  have  just  been  alluded  to  in  describing 
the  diagnosis  from  retinal  changes.  White  spots,  not  atro- 
phic,  are  the  result  of  inflammation,  or  growths — tubercle 
or  lymphadenoma.  The  latter  are  extremely  rare,  and  only 
occur  when  the  general  lymphatic  disease  is  well  marked. 
Tubercles  are  isolated  and  small — rarely  large.  Pigment 

1  "  Ophth.  Hosp.  Rep."  ix.  170. 


136  MEDICAL    OPHTHALMOSCOPY. 

may  be  seen  adjacent  to  the  older  formations.  The  evidence 
of  the  general  disease  is  almost  always  so  prominent  as  to 
prevent  the  possibility  of  error.  In  acute  choroiditis  the 
white  patches  are  large  and  numerous :  the  signs  of  the 
dyscrasise  associated  with  growths  are  absent,  and  there  is 
often  a  well-marked  history  of  syphilis.  The  results  of 
previous  choroiditis  are  very  conspicuous  atrophic  and  pig- 
mentary changes,  often  associated  with  pigmentary  deposits 
in  the  retina.  It  must  be  remembered  that  this  pigment 
frequently  occupies  only  or  chiefly  the  peripheral  portions  of 
the  choroid,  and  an  examination  confined  to  the  neighbour- 
hood of  the  optic  disc  may  be  insufficient  to  discover  it.  The 
changes  are  very  important,  on  account  of  the  frequency  with 
which  the  inflammation  causing  them  is  the  result  of  syphilis. 
They  are  also  interesting  to  the  physician  as  associated,  in 
some  other  cases,  with  evidence  of  a  family  tendency  to 
nervous  disease.1  It  is  possible  that  inherited  syphilis  may 
be  the  link  between  these  morbid  states. 

Choroidal  exudations  (local)  sometimes  occur  about  puberty, 
resembling  choroidal  tubercles,  and  it  has  been  suggested  that 
these  are  really  foci  of  scrofulous  or  tuberculous  inflammation. 

Chronic  choroidal  degenerations  sometimes  occur  as  a 
senile  change,  possibly  in  consequence  of  general  arterial 
degeneration.2  Circumscribed  changes  may  result  from 
haemorrhage.  Amyloid  degeneration  of  the  choroidal  arteries 
was  found  by  Kuapp  in  a  case  in  which  haemorrhage  occurred. 

Embolism  of  choroidal  vessels  was  believed  by  Knapp  to 
be  the  cause  of  morbid  appearances  in  two  cases  of  heart 
disease  observed  by  him.3  In  each  there  was  sudden  affec- 
tion of  sight,  at  first  general  and  then  central,  accompanied 
by  achromatopsy.  Corresponding  to  the  scotoma,  there  was 
a  localized  retinal  opacity  with  hyperoemia.  The  opacity, 
ascribed  to  effusion,  extended  to  the  optic  disc.  Sight,  and 
the  appearance  of  the  fundus,  ultimately  became  normal. 

1  Instances  of  this  have  been  related  by  Mr.  Nettleship.     ("  Ophth.  Hosp. 
Rep.,"  ix.  178.) 

2  Hutchinson  and  Tay  :  "Ophth.  Hosp.  Rep.,"  vol.  viii.     Poncet  :  "Ann. 
d'Oculist.,"  1875. 

3  "  Arch.  f.  Ophth.,"  Bd.  xiv. 


PAET    II. 

OPHTHALMOSCOPIC   CHANGES  IN  SPECIAL 
DISEASES. 

DISEASES   AND   INJUEIES    OF   THE    NERVOUS 

SYSTEM. 

DISEASES    OF   THE  BRAIN. 

IN  diseases  of  the  brain,  two  forms  of  ophthalmoscopic 
change  may  be  met  with : — Firstly,  those  which  are  a  con- 
sequence of  the  general  condition  by  which  the  cerebral 
disease  is  produced — associated  changes ;  and,  secondly,  those 
which  are  the  consequence  of  the  cerebral  disease — consecu- 
tive changes. 

ANAEMIA  AND  HYPER.EMIA  OF  THE  BRAIN. 

It  has  been  supposed  that  the  state  of  the  circulation 
in  the  eye  and  brain  correspond,  and  that  the  anaemia  and 
hypersemia  of  the  brain  are  revealed  by  similar  conditions  in 
the  fundus  oculi,  and  especially  in  the  vessels  of  the  retina 
and  optic  nerve ;  the  vascularity  of  the  choroid  being  too 
great  to  permit  of  the  recognition  of  any  change  in  its 
circulation.  But,  as  already  stated  (p.  19),  this  conclusion, 
if  true  at  all,  is  true  only  within  narrow  limits.  Local 
influences,  chiefly  perhaps  the  intra-ocular  tension,  so  in- 
fluence these  vessels,  that  they  undergo  little  alteration 
when  changes  occur  in  the  condition  of  the  vessels  of  the 
brain.  The  eyeball  participates  in  variations  in  the  blood- 
supply  to  the  whole  head,  but  it  does  not  share  simple 


138  MEDICAL    OPHTHALMOSCOPY. 

vascular  states  of  the  brain  (in  which  the  rest  of  the  head 
does  not  participate)  to  a  degree  that  can  render  it  an  index 
to  the  existence  of  those  states.  This  statement  applies 
especially  to  the  retinal  vessels :  it  is  in  these  that 
alterations  can  be  most  readily  perceived.  It  applies  also 
to  the  optic  nerve ;  but  in  this,  alterations  are  more  readily 
produced  by  encephalic  changes,  although  to  only  a  slight 
extent  and  not,  perhaps,  in  a  direct  manner. 

Cerebral  Hyperwmia. — There  is  no  sufficient  evidence  to 
show  that  the  vascularity  of  the  disc  or  retina  participates  in 
any  transient  cause  of  cerebral  congestion,  unless  the  whole 
head  suffers.  But  in  some  cases  of  long-continued  vascular 
disturbance,  and  in  morbid  states  which  are  ascribed,  with 
some  probability,  to  cerebral  congestion,  ophthalmoscopic 
changes  are  sometimes  to  be  seen — a  transient  increase  of 
colour,  sometimes  with  slight  blurring  of  the  edge.  But  in 
most  of  these  cases  there  is  evidence  of  grave  functional 
disturbance  of  the  brain  or  prolonged  hypersemia.  Instances 
are  such  congestions  as  are  shown  in  PI.  I.  1  and  2,  and 
the  bright  injection  of  the  discs  described  by  Macnamara 
as  occurring  during  the  headache  produced  by  exposure 
to  the  tropical  sun,  increasing  to  papillitis  when  actual 
meningitis  is  developed. 

This  conclusion — the  absence  of  any  marked  vascular 
alteration  in  the  eye  in  changes  in  the  cerebral  circulation — 
is  at  variance  with  early  statements  and  a  priori  theories ; 
but  it  is  abundantly  supported  by  skilled  observers.1 

1  See,  for  instance,  the  statements  of  Manz,  Schmidt-Rimpler,  and  others, 
at  the  discussion  at  Heidelberg,  reported  in  the  "  Ann.  d'Oculistique," 
vol.  Ixxiv.  1875,  p.  262,  et  seq. 

It  must  be  remembered  that  "  congestion  of  the  brain"  as  a  name  is 
exceedingly  convenient,  especially  to  those  who  are  called  "  ready  dia- 
gnosicians,"  but  for  whom  "unscrupulous  namers  "  would  be  a  more  exact 
designation.  Apart  from  these,  however,  the  condition  is  invoked  with  a 
readiness  that  cannot  but  excite  surprise  in  those  who  know  how  different 
is  the  significance  of  the  symptoms  it  is  considered  to  cause.  Further,  the 
evidence  that  may  suffice  for  "  practical  diagnosis  "  is  often  wholly  inadequate 
for  scientific  reasoning.  Very  red  discs,  simply  suggestive  of  cerebral 
congestion  alone,  prove  nothing.  To  be  of  significance  the  redness  must 
lessen  in  an  unequivocal  degree  as  the  symptoms  go. 


AXJEMIA    OF    THE    BRAIN.  139 

Lastty,  it  is  probable  that  when  cerebral  hypersemia  is 
due  to  blood  states,  the  cause  may  also  influence  the  optic 
disc  and  induce  congestion.  But  this  has  [not  yet  been 
proved. 

Amemia  of  the  Brain  is  rare  as  a  primary  vascular  con- 
dition, except  as  part  of  a  general  cephalic  anaemia.  It  is 
possible  that  in  the  same  stage  of  an  epileptic  fit  in  which 
there  is  pallor  of  the  face,  there  may  also  be  pallor  of  the 
disc ;  but  no  evidence  of  this  fact  has  at  present  been 
obtained,  and  it  is  unlikely.  Indeed,  it  is  questionable 
whether  any  diminution  in  the  tint  of  the  disc  has  ever 
been  observed  to  coincide  with  a  diminution  in  the  amount 
of  blood  within  the  brain  alone.  It  is  not  probable  that 
there  is  such  a  diminution  at  the  onset  of  an  epileptic  fit ; 
the  pallor  of  face  usually  precedes  instead  of  following  the 
onset. 

When  the  cerebral  anaemia  is  part  of  a  similar  state 
affecting  the  whole  head,  the  retina  certainly  participates, 
although  it  is  not  ofteu  that  an  opportunity  is  obtained  of 
observing  this  with  the  ophthalmoscope.  But  loss  of  function 
of  the  retina  affords  evidence  of  its  participation;  transient 
loss  of  sight,  probably  from  this  cause,  may  follow  syncopal 
seizures.  In  an  instance  that  came  under  my  observation, 
a  lad  engaged  in  a  stooping  occupation  in  a  hot  crowded 
room,  felt  faint,  and  went  out  into  the  cool  night-air.  On 
re-entering  the  room  he  could  not  see  :  the  room  was 
absolutely  dark  to  him.  After  sitting  still  for  a  few  minutes 
sight  slowly  returned.  It  is  hardly  conceivable  that  the  loss 
of  sight  was  the  result  of  anaemia  of  the  brain,  because  the 
other  cerebral  functions  were  scarcely  affected,  and  the  loss 
of  sight  persisted  after  he  otherwise  felt  quite  well. 
Probably  the  retina  shared  the  cephalic  anaemia  (due 
to  heart-failure),  and  suffered  in  function  more  and  longer 
than  the  brain.1 

1  This  fact  is  one  ot  some  significance.  It  suggests  how  extremely 
sensitive  the  retina  is  in  its  function,  and  therefore  must  be  in  its  nutrition, 
to  sudden  influences. 


140  MEDICAL    OPHTHALMOSCOPY. 


INFLAMMATION  OF  THE  BRAIN. 

Acute  general  inflammation  of  the  brain  cannot  occur 
except  in  association  with  meningitis.  The  latter  is  the 
predominant  lesion,  and  to  it  the  symptoms  are  customarily 
ascribed.  Certainly,  of  ophthalmoscopic  changes  in  acute 
inflammation  of  brain  without  meningitis,  we  know  nothing. 
Of  course  such  cases  of  "  active  hypersemia "  as  those 
described  in  the  last  section,  as  occurring  from  the  effects 
of  insolation,  may  be  regarded  as  cases  of  encephalitis. 
There  is  no  sharp  line  to  be  drawn  between  "  active  con- 
gestion "  and  "  inflammation,"  but  there  appear  to  be  no 
pathological  facts  to  warrant  us  in  regarding  the  morbid 
process  in  these  cases  as  actual  inflammation.  Local  acute 
inflammation  is  probably  always  secondary.  But  it  is 
probable  that  any  local  inflammation  of  the  brain  will  cause 
neuritis  if  it  continues  for  a  sufficient  time. 

There  is,  however,  a  class  of  cases  to  which  the  term 
"  chronic  encephalitis,"  or,  perhaps,  more  accurately,  "  chronic 
cerebritis,"  appears  fully  applicable,  and  in  which  there  may 
be  very  marked  ophthalmoscopic  changes.  These  cases  pre- 
sent evidence  of  mental  and  motor  failure,  the  latter  may  be 
local  and  attended  by  convulsion.  Death  may  be  preceded  by 
coma.  Headache  is  often  severe.  There  are  not  the  tremors 
or  mental  peculiarities  of  general  paralysis,  the  symptoms 
resembling  much  more  closely  those  of  cerebral  tumour. 
Post-mortem  there  is  no  sign  of  meningitis  ;  the  brain  may 
present  evidence  of  degeneration,  sometimes  of  wasting,  but 
no  "  focal "  disease.  Such  cases  may  be  attended  by  optic 
papillitis  very  similar  to  that  found  in  cerebral  tumour,  due 
most  probably  to  the  propagation  of  an  irritative  process 
from  the  cerebrum  along  the  nerves.  A  well-marked  case  of 
this  kind  has  been  described  by  Hughlings-Jackson.1  Dr. 
Button's  microscopical  examination  of  the  convolutions  showed 

1  "  Ophth.  Hosp.  Rep.,"  viii.  445. 


INFLAMMATION    OF    THE    BRAIN.  141 

only  an  undue  number  of  the  "  spherical  nuclear  bodies,"  and 
in  places,  instead  of  the  normal  pyramidal  nerve  cells,  were 
large  numbers  of  staining  nuclei,  with  unstaining  cell-bodies 
around  them.  In  places  these  nuclei  were  aggregated  into 
groups  of  ten  or  twenty.  The  neuroglia  was  more  granular 
than  that  of  a  healthy  brain.  The  optic  nerves,  examined 
by  myself,  presented  the  characteristics  of  moderate  papillitis, 
the  swollen  papillae  being  infiltrated  with  nuclear  bodies 
similar  to  those  seen  by  Dr.  Sutton  in  the  brain.  Similar 
corpuscles  were  so  abundant  throughout  the  optic  nerves 
as  to  justify  the  assumption  that  the  neuritis  had  been 
"  descending  "  (Pigs.  47,  48).  A  case  published  by  Noyes,  in 
1873,  was  probably  similar.  Double  optic  neuritis,  passing 
into  atrophy,  was  accompanied  by  severe  pain  in  the  head, 
and  paralysis  of  various  cerebral  nerves  and  unsteady  gait. 
After  death,  no  lesion  of  the  brain  was  discovered.  More 
recently,  a  well-marked  case  of  the  same  kind,  also  accom- 
panied by  optic  neuritis,  has  been  recorded  by  Stephen 
Mackenzie.1 

In  the  rare  cases  in  which  haemorrhage,  or  softening  from 
vascular  occlusion,  causes  optic  neuritis,  the  effect  is  doubtless 
produced  through  the  agency  of  secondary  inflammation. 

Cases  are  sometimes  met  with  in  which  we  have  a  diffi- 
culty in  assigning  to  inflammation  or  growth  the  chief  share 
in  the  morbid  process.  Such  cases  may  be  accompanied  by 
descending  neuritis,  and  simulate  closely  the  symptoms 
of  cerebral  tumour.  PL  VI.  Fig.  2  shows  the  optic  disc  in 
such  a  case.  In  this  case,  local  injury,  years  before,  had 
caused  the  production  of  cheesy  degenerating  tissue  beneath 
the  membranes  over  certain  convolutions,  and  a  more  widely 
spread  but  irregularly  distributed  meningitis  had  led  to 
vascular  disease,  from  the  effects  of  which  the  patient  died. 
The  optic  nerves  were  infiltrated  with  leucocytes,  and 
"  miliary  abscesses  "  were  found  in  the  optic  tracts  (Figs. 
23  and  33). 

1  "  Brain,"  vol.  ii.  p.  257. 


142  MEDICAL    OPHTHALMOSCOPY. 


CEREBRAL  HEMORRHAGE. 

Associated  Cluing es. — The  common  form  of  cerebral 
haemorrhage  is  due  to  the  rupture  of  "  miliary  aneurisms  "  ; 
that  is,  minute  arteries  suffer  in  the  nutrition  of  their  wall, 
which  yields  before  the  blood-pressure,  and  the  dilatations 
thus  produced  are  called  aneurisms.  The  conditions  which 
give  rise  to  these  aneurisms  seldom  influence  the  arteries  of 
the  retina,  but  the  capillaries  suffer  in  a  similar  manner  very 
frequently,  and  thus  small  extravasations  occur.  In  Fig. 
3,  p.  17,  are  shown  capillary  aneurisms  from  a  case  in 
which  cerebral  and  retinal  haemorrhages  coexisted.  These 
associates,  retinal  and  cerebral  aneurisms,  occur,  however, 
almost  exclusively  rin  kidney  disease.  Aneurisms  on  small 
arteries,  the  true  "miliary  aneurisms,"  are  rare.  Probably 
this  is  due  to  the  uniform  support  afforded  to  the  arteries  of 
the  eye.  Aneurisms  are  also  depicted  in  PL  XII.  from  a 
case  in  which  all  the  conditions  for  the  production  of  cerebral 
haemorrhage  were  present  in  extreme  degree.  It  is  taken 
from  a  woman  aged  thirty-six,  who  had  advanced  kidney 
disease  with  great  cardiac  hypertrophy,  and  very  high 
arterial  tension.  On  ophthalmoscopic  examination  there 
was  obvious  change  in  the  coats  of  all  the  branches  of  the 
retinal  artery — chiefly  thickening  of  the  outer  coat.  There 
were  several  large  haemorrhages,  and  in  a  few  places 
aneurismal  dilatation  of  the  vessel. 

Retinal  Hemorrhages,  however,  are  present  in  a  consider- 
able number  of  cases  of  cerebral  haemorrhage,  and  furnish  an 
indication  of  considerable  value.  Their  most  frequent  cause 
is  that  which  is  the  most  frequent  cause  of  cerebral  haemor- 
rhage, Bright's  disease,  especially  the  granular  kidney. 
They  may  exist,  as  in  PI.  IX.  1,  without  any  other  retinal 
change,  or  may  form  part  of  the  special  retinitis  (PI.  X.  1 
and  XII.  1).  In  either  case  they  indicate  the  existence  of 
the  conditions  which  favour  vascular  degeneration  and 
rupture.  In  the  retina  shown  in  PI.  X.  1,  for  instance, 


CEREBRAL    HAEMORRHAGE.  143 

capillary  dilatations  and  other  changes  were  found. 
The  retinal  haemorrhages  are  often  associated  with  cardiac 
hypertrophy.  They  thus  may  accompany  all  the  most 
potent  causes  of  cerebral  haemorrhage.  It  must  not  be  con- 
cluded, however,  that  the  presence  of  albuminuric  retinitis 
proves  a  cerebral  lesion  to  be  haemorrhagic.  The  disease  of 
the  kidneys  is  a  cause,  not  only  of  the  minute  aneurisms  that 
lead  to  haemorrhage,  but  also  of  the  atheroma  of  the  larger 
arteries  that  leads  to  thrombosis  within  them.  Hence, 
softening  due  to  the  closure  of  atheromatous  arteries  is 
often  associated  with  retinal  changes  due  to  kidney  disease, 
and  the  latter  have  little  weight  in  the  differential  diagnosis. 
They  point  strongly  to  one  of  these  two  lesions,  but  leave 
uninfluenced  the  indications  furnished  by  the  state  of  the 
heart  and  the  character  of  the  onset. 

In  other  conditions  retinal  haemorrhages  have  a  similar 
significance.  They  point  to  a  state  in  which  cerebral  haemor- 
rhage is  likely  to  occur.  Their  significance  is  also  more 
decided,  since  these  other  causes  of  retinal  haemorrhage  do 
not  produce  arterial  atheroma.  They  occur,  for  example,  in 
pernicious  anaemia  (PI.  XI.  1)  and  in  leucocythaemia  (PL 
XI.  2),  and  in  the  latter  disease  the  brain  stands  second  in 
frequency  as  the  seat  of  internal  haemorrhage.1 

But  although  retinal  haemorrhages  point  to  the  existence  of 
conditions  such  as  may  lead  to  cerebral  haemorrhage,  and  are 
thus  of  great  importance  as  indications  of  the  need  for  care 
in  avoiding  the  exciting  causes  of  haemorrhage,  their  signifi- 
cance as  indications  of  the  probability  of  the  occurrence  of 
apoplexy  may  be  overrated.  They  are  not  uncommon,  as  in 
old  and  gouty  persons,  who  do  not  suffer  subsequently  from 
cerebral  haemorrhage.  Perhaps  this  is,  in  part,  due  to  the 
fact  that  the  conditions  in  which  they  arise  are  such  that 
many  other  causes  of  death  coexist.  Moreover,  the  existence 
of  the  conditions  favourable  to  an  event  does  not  necessarily 
involve  a  balance  of  probability  in  favour  of  the  occurrence 
of  that  event. 

1  Retinal  haemorrhages  not  included.  See  the  writer's  article  on  "  Leu- 
cocythsemia,"  "Reynolds'  System  of  Medicine,"  vol.  v. 


144  MEDICAL    OPHTHALMOSCOPY. 

Among  the  very  rare  causes  of  cerebral  haemorrhage  are 
syphilis  and  heart  disease;  the  occasional  changes  in  the 
fundus  may  thus  conceivably  be  of  service  in  the  differential 
diagnosis,  that  from  heart  disease  being  embolism.  The 
coincidence  has  not,  however,  been  hitherto  observed.  One 
reason  for  this  may  be  that  the  haemorrhage  from  these 
causes  is  usually  due  to  the  rupture  of  an  aneurism,  and  is 
seldom  survived. 

Consecutive  Changes. — Haemorrhage  into  the  substance  of 
the  brain  is  not  usually  attended  with  any  ophthalmoscopic 
changes.  So  rarely  have  any  alterations  in  the  fundus  been 
seen,  that  they  may  be  said  almost  never  to  occur  during  the 
first  few  weeks  after  the  onset.  Neuritis  has,  however,  been  met 
with  in  a  few  instances.  But  its  rarity  is  so  great  that  the 
question  arises  whether,  when  met  with,  it  has  really  been  due 
to  the  cerebral  lesion ;  and  the  question  is  certainly  justified, 
because  other  causes  of  optic  neuritis  are  seldom  absent  in 
cerebral  haemorrhage.  Kidney  disease  and  constitutional 
gout  are  sufficient  to  explain  the  occurrence  of  optic  neuritis 
when  it  exists  alone,  and  equally  so  when  it  is  met  in  associa- 
tion with  a  malady  that  has  not  yet  been  proved  to  be,  alone, 
an  adequate  cause.  But  here,  as  in  so  many  other  conditions, 
the  insufficiency  of  a  cause  acting  alone,  does  not  exclude  some 
influence  when  it  is  in  association  with  some  other  cause. 
There  is  evidence  that  inflammation  of  the  brain  will  produce 
optic  neuritis,  and  that  any  process  that  excites  second- 
ary inflammation  may  therefore  assist  in  the  causation. 
Haemorrhage  always  causes  such  secondary  inflammation, 
just  as  does  a  traumatic  lesion  of  the  brain.  Indeed  cerebral 
haemorrhage  may  be  regarded  as  a  traumatic  lesion  which  has 
no  external  origin.  Although  the  secondary  inflammation 
seems  to  be  insufficient,  alone,  to  excite  optic  neuritis,  it  may 
determine  the  occurrence  in  conjunction  with  so  potent  a 
cause  as  the  blood-state  of  gout,  or  that  produced  by  kidney 
disease.  This  is  probably  the  explanation  of  the  few  cases  in 
which  considerable  optic  neuritis  has  been  observed  in  cases 
of  pure  haemorrhage.  One  such  case  has  been  described  by 
Hughlings- Jackson ;  ten  weeks  after  an  attack  of  cerebral 


CEREBRAL    HAEMORRHAGE.  145 

haemorrhage,  the  discs  presented  the  appearances  of  the  later 
stage  of  neuritis.  The  patient  died  a  week  subsequently, 
and  the  necropsy  revealed  a  large  extravasation  into  the 
middle  cerebral  lobe,  and  a  few  specks  of  haemorrhage  into 
the  corpora  quadrigemina.  Another  case  is  recorded  by 
Bristowe.1  The  haemorrhage  was  in  the  posterior  part  of  the 
optic  thalamus.  Robin2  mentions  a  case  with  well-marked 
neuritis,  such  as  is  met  with  in  tumours,  in  which  the  autopsy 
revealed  a  clot  of  blood,  the  size  of  a  walnut,  compressing 
the  pons.  In  this  case  the  neuritis  can  hardly  have  been 
the  result  of  the  extravasation.  In  a  case  described  by 
Gemuseus,3  double  neuro-retinitis  was  observed  during  life, 
and,  after  death,  numerous  haemorrhages  were  found  in  the 
brain. 

In  many  cases  of  intense  optic  neuritis  met  with  in  cerebral 
haemorrhage,  the  blood  has  been  extravasated  into  a  soft 
growth  in  the  brain,  to  which  the  neuritis  has  really  been  due. 
In  one  case,  in  which  the  neuritis  had  been  watched  during 
life,  a  careful  observer  who  made  the  post-mortem  reported  a 
large  clot  surrounded  by  secondary  softening,  but  the  latter 
was  really  a  very  soft  grey  glioma  into  which  the  haemor- 
rhage had  occurred. 

When,  however,  the  haemorrhage  is  into  the  meninges, 
ocular  changes  may  exist — slight  optic  neuritis.  The  haemor- 
rhage may  pass  into,  and  distend,  the  sheath  of  the  optic 
nerve,  as  has  been  found  (in  a  case  of  my  own)  in  meningeal 
haemorrhage  from  fracture  of  the  skull,  in  rupture  of  an 
aneurism  of  the  middle  cerebral  (Mackenzie) ,  in  rupture  of  an 
intra-cerebral  extravasation  into  the  meninges  (Michel),  and 
in  haemorrhagic  pachymeningitis  (Manz).  Opacity  and  blur- 
ring of  the  outline  of  the  disc  with  slight  swelling  may  be 
thus  produced.  Retinal  extravasations  may  co-exist,  as  in 
a  case  figured  by  Poncet.4  Early  changes  in  the  papilla,  in  a 

1  "  Trans.  Ophth.  Soc.,"  vi.  363. 

2  "  Des  Troubles  Oculaires  dans  les  Maladies  de  1'Encephale,"  Paris,  1880, 
p.  284. 

3  "Klin.  Monatslil.  f.  Augenheilk.,"  1880,  p.  380. 

4  "  Atlas  "  of  Perrin  and  Poncet. 

L 


146  MEDICAL   OPHTHALMOSCOPY. 

case  of  undoubted  cerebral  haemorrhage,  would  thus  be  evi- 
dence that  the  blood  was  effused  into  the  meninges.  It  is 
said  (by  Knapp  and  Liebreich)  that  a  peculiar  pigmentation 
of  the  outer  peripheral  part  of  the  disc,  within  the  sclerotic 
ring,  may  be  an  ultimate  consequence  of  such  haemorrhage. 

In  rare  cases  optic  nerve  atrophy  has  been  met  with  in 
association  with  cerebral  haemorrhage.  Thus  a  case  is 
recorded  by  Vulpian1  in  which  blindness  supervened  on  an 
attack  of  apoplexy.  Death  occurred  fifteen  years  later,  and 
the  remains  of  an  old  haemorrhage  were  found  in  the  left 
corpus  striatum.  Both  optic  nerves  and  optic  tracts 
presented  grey  atrophy.  The  connection  between  the  two  is 
probably  indirect. 

CEREBRAL  SOFTENING. 

In  softening  of  the  brain,  marked  ophthalmoscopic  changes 
are  rare  as  the  result  of  the  cerebral  mischief,  although  occa- 
sionally present,  as  several  reliable  cases  testify;  and  I 
believe  that  slight  changes  are  more  common  than  in  cerebral 
haemorrhage.  Most  of  the  cases  in  which  alterations  have 
been  found  have  been  cases  of  softening  from  embolism,  not 
from  thrombosis  secondary  to  vascular  disease.  Changes  in 
the  fundus  oculi,  moreover,  sometimes  result  from  the  same 
causes  as  those  which  lead  to  the  cerebral  mischief. 

1.  EMBOLIC  SOFTENING  :  (a)  Associated  Changes. — Em- 
bolism of  the  trunk  or  of  a  branch  of  the  central  artery  of 
the  retina  may  occur  before  or  after  embolism  of  a  cerebral 
artery ;  very  rarely  at  the  same  time  (see  p.  34.).  When  the 
two  occur  at  the  same  moment,  the  demonstration  of  the 
nature  of  a  cerebral  lesion  is  brought  almost  to  its  most 
complete  form.  The  only  defect  in  the  demonstration  is 
that  the  plug  in  the  artery  cannot  actually  be  seen.  An 
instance  of  such  coincidence  is  afforded  by  the  case  illustrated 
in  PI.  XII.  2.  In  this,  however,  the  proof  was  completed 

1  Galezowski :  "Journal  d'Ophthalmologie,"  Jan.  1872. 


CEREBRAL    SOFTENING.  147 

by  post-mortem  inspection.     The  plug  in  the  retinal  artery 
is  shown  in  Fig.  4,  p.  36.1 

(i)  Consecutive  Changes. — When  the  artery  plugged  is  the 
middle  cerebral,  marked  disturbance  of  the  circulation  might 
be  expected  in  the  eye  which  derives  its  blood-supply  from 
the  same  trunk.  Any  signs  of  such  disturbance  have,  how- 
ever, hitherto  escaped  attention,  and  probably  the  free 
anastomoses  of  the  circle  of  Willis  carry  off  any  excess  of 
pressure. 

If  the  condition  of  the  discs  is  carefully  observed  from 
time  to  time,  I  believe  that  a  state  of  congestion  may  often 
be  observed  a  few  weeks  after  the  onset  of  embolic  softening, 
especially  in  those  cases  in  which  the  cerebral  damage  is 
extensive  and  leads  to  mental  change.  PL  I.  Figs.  1  and  2 
show  such  an  appearance  in  a  young  man  with  mitral 
disease  and  left  hemiplegia.2  Actual  neuritis  has  been 
observed  in  a  few  cases,  distinct,  moderate  in  intensity, 
coming  on  a  few  days  or  weeks  after  the  cerebral  lesion, 
running  a  subacute  course,  and  slowly  subsiding.  One  of 
the  best  marked  cases  of  the  kind  has  been  recorded  by 
Broadbent,3  in  a  man,  aged  nineteen,  with  mitral  disease, 
who  was  seized  with  left  hemiplegia  and  impairment  of  sen- 
sation. Nine  days  after  the  onset  of  the  hemiplegia  the 
margins  of  the  optic  discs  were  ill-defined ;  there  was 
swelling,  with  an  unduly  vascular  "  woolly  "  appearance,  the 
retinal  veins  were  large,  dark,  and  tortuous,  the  arteries 
visible,  but  small.  By  the  eighteenth  day  the  paralysis  had 
improved  considerably,  but  the  papillitis  persisted,  sight 
being  normal.  Six  weeks  after  the  onset,  he  was  walking 
about  the  ward,  and  the  papillitis  was  subsiding.  A  fort- 
night later  the  outlines  of  the  discs  were  becoming  perceptible, 

1  For  fuller  details  see  description  of  the  plate. 

2  The  increased  redness   of  the   disc,  with   slightly  softened    outline  to 
indirect    image,   developed    in    both   eyes  under  observation,    and  was   so 
marked  that  I  thought  neuritis  was  coming  on.     It  became  stationary,  how- 
ever ;  soon  lessened  in  the  left  eye,  and  much  more  slowly  in  the  right. 
Coincidently  with  it  there  was  marked  and  increasing  mental  failure,  persistence 
of  the  complete  hemiplegia,  and  rapid  development  of  the  ankle-clonus. 

3  "Cliii.  Trans.,"  vol.  ix.  1876,  p.  62 


148  MEDICAL    OPHTHALMOSCOPY. 

the  papillae  being  still  red  and  rather  prominent.  He  sub- 
sequently had  some  convulsive  attacks  and  symptoms  of 
ulcerative  endocarditis,  and  died  four  months  after  the  onset 
of  the  hemiplegia.  There  was  softening  below  the  posterior 
cornu  of  the  right  lateral  ventricle,  extending  to  the  tip  of 
the  occipital  lobe,  and  involving  the  tail  of  the  corpus 
striatum  and  the  fibres  passing  from  the  thalamus  to  the 
occipital  lobe.  The  part  softened  was  in  the  region  of  the 
posterior  cerebral,  but  no  obstruction  of  this  vessel  was 
found ;  the  calcarine  artery  could  not  be  traced. 

Double  neuritis,  with  slight  changes  in  the  contiguous 
retina,  was  seen  by  Stephen  Mackenzie1  in  a  case  of  left 
hemiplegia,  no  doubt  the  result  of  embolism  of  the  right 
middle  cerebral  artery.  The  softening  found  five  weeks  after 
the  onset  was  slight,  and  the  middle  cerebral  was  pervious, 
although  thickened,  the  probability  being  that  the  plug  had 
broken  up  and  had  been  carried  on  into  some  of  the  terminal 
branches  of  the  artery.  Splenic  infarctions  were  also  found. 
Three  days  after  the  onset,  the  discs  (previously  normal)  were 
swollen,  and  three  weeks  later  the  swelling  persisted,  but 
with  a  good  deal  of  opacity,  the  vessels  being  "  buried  in 
exudation."  One  or  two  haemorrhages  existed  close  to  the 
discs.  The  appearance  of  the  discs,  Dr.  Mackenzie  has  in- 
formed me,  was  precisely  that  often  seen  in  cerebral  tumour. 

A  grey  infiltration,  incompletely  veiling  the  disc,  and 
extending  into  the  adjacent  retina,  is  figured  by  Bouchut 
from  a  case  of  hemiplegia  in  a  child  of  seven  years  with 
mitral  regurgitation. 

Most  of  the  above  cases  seem  to  be  distinct  instances  of  the 
association  of  neuritis  and  softening.  It  is  important  to 
note  that  all  were  cases  of  softening  from  embolism,  that  in 
most  the  plug  came  from  valves  the  seat  of  actual  recent 
inflammation,  and  that  in  some  the  development  of  the  optic 
neuritis  was  accompanied  by  evidence  of  wide-spiead  dis- 
turbance of  the  cerebral  functions.  There  is  nothing  in  the 
mere  process  of  necrotic  softening,  the  mere  breaking  up 
of  the  nerve-elements  into  discontinuous  particles  separated 
1  "  Brain,"  Jan.  1879. 


CEREBRAL    SOFTENING.  149 

by  liquid,  which  can  cause  optic  neuritis,  according  to  our 
present  knowledge.  But  the  process  is  never  one  of  simple 
necrosis  of  the  tissue-elements.  Adjacent  inflammation 
always  accompanies  it  just  as  it  does  the  suppuration  of  a 
gangrenous  foot.  Inflammation  in  parts  of  the  body 
shows  wide  variations  in  its  character,  variations  which 
at  present  are  imperfectly  understood  but  are  certainly  of 
vast  importance.  One  of  the  differences  in  character  is 
the  tendency  to  spread.  It  is  certain  that  emboli  from  an 
inflamed  cardiac  valve  have  a  special  power  of  exciting 
inflammation — a  power  which  is  ascribed,  with  much  plausi- 
bility, to  the  presence  of  organisms  within  them.  The 
inflammation  thus  excited  or  conveyed  varies  in  its  intensity 
and  in  its  tendency  to  spread,  just  as  the  inflammation  in 
the  heart  seems  to  vary  in  its  "  malignancy."  It  is  in- 
evitable, therefore,  that  in  some  cases  the  inflammation  that 
is  secondary  to  the  process  of  necrosis  should  have  its 
character  modified  by  the  influence  of  the  plug ;  the 
organisms  of  it,  if  organisms  are  the  morbific  agents,  may 
readily  find  their  way  into  the  inflamed  brain  tissue  and 
determine  characteristics  possibly  more  extensive  than  the 
immediate  influence  of  the  presence  of  the  organisms  them- 
selves. And  it  is  thus  inevitable  that  the  cases  should 
present  such  differences  as  we  have  noticed,  and  that  in 
some  the  spread  of  the  irritative  process  should  lead  to  an 
optic  neuritis,  slight  or  severe,  which  is  absent  in  other  cases. 
It  may  be  well,  however,  again  to  remark  how  easily  the 
error  may  be  made  of  mistaking  a  soft  glioma  for  a  patch 
of  softening.1 

1  The  following  case  has  been  recorded  by  Drs.  Darby  and  Upham 
("Boston  Med.  and  Surg.  Journal,"  vol.  Ixxii.)  as  one  of  softening,  in  which, 
however,  there  was  no  evidence  of  embolism.  A  man  aged  twenty-six  had 
a  hemiplegic  attack,  followed  by  fits  and  double  "  neuro-retinitis  "  with 
haemorrhages.  A  necropsy  some  months  later  revealed  a  peculiar  softening 
of  the  corpus  striatum  and  optic  thalamus,  grey  and  white  gelatinous  soft 
tissue,  to  the  naked  eye  very  like  a  glioma,  but,  on  microscopic  examination, 
only  the  signs  of  degeneration  were  visible.  It  is  to  be  remarked,  however, 
that  many  parts  of  these  tumours  may  contain,  and  even  appear  to  consist 
only  of,  products  of  degeneration.  A  careful  search  may  be  necessary  for  the 
very  delicate  cells  of  which  they  consist. 


150  MEDICAL    OPHTHALMOSCOPY. 

In  a  case  recorded  by  Leber  of  supposed  neuritis  from 
softening,  the  fact  that  the  "softening"  was  a  soft  glioma 
was  not  suspected;  the  nature  of  the  lesion  was  only  dis- 
covered on  microscopic  examination. 

Atrophy  of  one  optic  nerve  is  said  to  succeed  softening, 
embolic  or  other,  just  as  it  has  been  observed  to  succeed 
haemorrhage.  This  result  is  supposed  to  be  due  to  the  seat 
of  the  lesion  being  such  as  to  damage  the  nutrition  of  some 
part  of  the  brain  to  which  the  optic  fibres  are  related. 
Embolism  of  the  middle  meningeal  artery,  which  supplies 
the  dura  mater  near  the  optic  nerve,  is  said  also  to  cause 
atrophy  of  the  latter. 

2.  SOFTENING  FROM  THROMBOSIS. — (1)  Arterial — This 
may  be  due  to  syphilitic  or  degenerative  disease  of  the 
vessels,  or  to  blood-changes. 

Syphilitic  Disease. — In  softening  from  syphilitic  disease 
of  vessels,  associated  ophthalmoscopic  changes  are  common, 
consecutive  changes  are  very  rare.  The  associated  conditions 
are  the  various  changes  which  are  due  to  syphilis,  and  which 
need  not  be  mentioned  here.  They  come  practically  under 
the  cognisance  and  teaching  of  the  ophthalmic  surgeon.  This 
is  because  their  active  stage  affects  sight  and  seldom  coin- 
cides with  disease  elsewhere.  But  the  changes  in  the  eye  in 
inherited  syphilis  come  very  often  under  the  notice  of  the 
physician,  and  in  both  the  inherited  and  acquired  diseases 
the  relics  of  the  syphilitic  disease  are  of  extreme  value  to 
the  physician.  Among  the  diseases  in  which  their  signi- 
ficance is  of  the  greatest  importance  are  those  now  under 
consideration. 

In  cerebral  softening  such  indications  are,  of  course,  of  the 
greatest  significance  in  the  case  of  persons  who  have  not 
reached  the  period  of  life  at  which  vascular  degeneration  is 
common.  In  the  latter  condition,  the  recognition  of  con- 
stitutional syphilis  still  leaves  us  in  some  doubt,  and  care 
must  be  taken  to  avoid  attaching  undue  weight  to  its  signs. 
Causal  indications  are  of  significance,  in  general,  in  proportion 
to  their  isolation.  At  the  same  time  it  must  not  be  forgotten 


CEREBRAL    SOFTENING.  151 

that  syphilitic  vascular  disease  does  occur,  and  not  rarely,  in 
the  degenerative  period.  Syphilitic  disease  and  atheroma 
have  been  observed  post-mortem  in  the  same  individual.  In 
doubtful  cases,  the  recognition  of  the  ocular  signs  of  syphilis 
should  always  lead  to  a  trial  of  the  special  remedies. 

Although  associated  changes  are  common,  consecutive 
alterations  in  the  eye  are  very  rare  in  softening  from 
syphilitic  disease  of  vessels.  Only  one  case  has  yet  been 
recorded  in  which  congestion  or  inflammation  of  the  optic 
papilla  was  apparently  due  to  this  cause.  The  proof  can 
only  be  given  by  pathological  demonstration  of  the  absence 
of  any  other  morbid  process.  The  case  is  one  described  by 
Leyden,  but  it  is  not  quite  conclusive,  since  the  inflammation 
of  the  papilla  may  have  been  a  primary  lesion.1  In  the  few 
recorded  cases  in  which  such  changes  were  observed,  syphilitic 
growths  in  the  brain  were  associated  with  the  vascular 
disease,  and  the  ocular  change  was  due  to  the  former,  not 
to  the  latter.  I  have  met  with  one  case  in  which  a 
fortnight  after  the  sudden  onset  of  hemiplegia,  in  a  patient 
who  had  had  constitutional  syphilis,  there  was  slight 
distinct  optic  neuritis  ;  but  the  absence  of  growths  could 
not  be  excluded,  and  preceding  pain  in  the  head  for  six 
months  rendered  it  probable  that  there  was  more  than  arterial 
disease. 

In  all  cases  of  this  kind  the  question  arises,  can  the  coin- 
cident papillitis  be  an  independent  effect  of  the  syphilitic 
poison  ?  This  question  we  cannot  at  present  answer  with  a 
positive  negation.  Syphilis  probably  can  cause  a  retro-ocular 
neuritis ;  it  certainly  can  cause  retinitis  involving  the  pa- 
pilla. Isolated  double  papillitis  may  be  an  effect  of  many 
morbid  states  of  the  blood,  varied  in  character,  with  a  virus 

1  "Zeitsch.  f.  Klin.  Med.,"  1882,  Bd.  ii.  p.  173.  The  patient,  a  man 
aged  eighteen,  died  from  limited  softening  of  the  inner  part  of  the  right  crus 
and  adjacent  part  of  the  pons,  due  to  syphilitic  disease  of  the  extremity  of 
the  basilar  artery  ;  and  seven  days  after  the  onset  of  the  acute  symptoms 
there  was  found  "  neuro-retinitis  with  choked  disc  as  in  cerebral  tumour  " 
(Dr.  Hiller),  although  no  other  lesion  than  syphilitic  disease  of  the  vessels 
could  fee  found.  The  details  from  an  ophthalmoscopic  point  of  view  leave 
much  to  be  desired. 


152  MEDICAL   OPHTHALMOSCOPY. 

organized  or  inorganic,  and  cases  are  met  with  possibly 
presenting  a  pure  syphilitic  papillitis.  Thus  this  possibility 
constitutes  at  present  an  unbridged  break  in  the  proof 
that  softening  from  syphilitic  disease  of  the  vessels  causes 
papillitis.  The  difficulty  is  the  greater  in  proportion  as  the 
papillitis  is  intense.  It  then  exceeds  the  degree  met  with 
even  in  softening  from  irritative  embolism,  and  on  the  other 
hand  resembles  that  of  which  the  chief  causes  are  tumours 
and  blood-states. 

Degenerative  Disease :  "Atheroma" — Cerebral  softening  from 
this  cause  is  rarely  associated  with  any  similar  morbid  state 
of  the  retinal  arteries,  which  are  below  the  size  in  which 
"  endarteritis  deformans  "  is  common.  Occasionally,  thick- 
ening of  the  wall  or  undue  tortuosity  of  the  retinal  arteries 
has  been  observed.  But  it  is  doubtful  whether  the  appear- 
ances that  have  been  described  as  atheroma  are  really  such, 
or  if  this  state  has  ever  really  been  met  with.  The  malady 
is  an  affection  of  the  inner  coat,  and  such  alterations  as  are 
depicted  in  PL  XII.  Fig.  1  are  manifestly  seated  in  the 
outer  coat  of  the  vessel  or  in  its  sheath.  Changes  in  the 
retina  in  the  old  have  been  ascribed  to  atheroma  lessening 
the  blood-supply,  but  such  an  inference  has,  of  course,  no 
bearing  on  the  question  whether  atheroma  occurs  or  not. 

Atheroma  of  cerebral  vessels  is  very  common  in  cases  of 
chronic  kidney  disease,  and  it  is  in  them  that  these  appear- 
ances have  been  chiefly  seen,  but  this  does  not  prove  their 
nature.  Various  elements  in  the  retina  suffer  in  renal 
disease,  and  hence  all  forms  of  albuminuric  retinitis  may  be 
associated  with  cerebral  softening.  They  are  also  associated  r 
in  the  same  manner,  with  cerebral  haemorrhages,  and  hence 
the  affection  of  the  retina  and  even  haemorrhages  in  it 
are  evidence  only  of  probable  disease  of  the  arteries  of  the 
brain.  In  the  case  figured  in  PL  IX.  1,  for  instance, 
although  there  was  a  retinal  haemorrhage  due  to  the  effect 
of  chronic  renal  disease,  the  cerebral  symptoms  pointed 
unmistakably  to  softening  rather  than  to  haemorrhage. 

Consecutive  changes  are  very  rare  in  senile  arterial  throm- 
bosis. Optic  neuritis  certainly  due  to  this  cause  is  scarcely 


CEREBRAL    SOFTENING.  ]  53 

ever  met  with.  Its  occurrence  would  not  be  surprising, 
since  the  secondary  inflammation  about  an  infarcted  area 
might  be  adequate  to  cause  it,  but  practically  it  is  almost 
unknown.  A  case  of  optic  neuritis,  however,  with  and 
apparently  due  to,  atheromatous  softening  is  recorded  by 
Wilbrand.1  In  some  cases  on  record  it  is  most  probable 
that  the  papillitis  was  nephritic — a  source  of  fallacy  to  be 
carefully  borne  in  mind.2  Atrophy  of  the  discs  has,  in  rare 
cases,  been  observed  to  supervene. 

In  some  cases,  however,  the  obstruction  by  thrombosis  of 
the  internal  carotid  may  give  rise  to  alterations  in  the  eye, 
which  have  been  hitherto  observed  only  after  death,  but 
which  must  be  attended  by  marked  ophthalmoscopic  changes. 
Such  a  case  was  described  long  ago  by  Yirchow.3  A  man 
aged  forty-six  who  had  an  attack  of  apoplexy,  leaving  right 
hemiplegia,  died  from  a  melanotic  cancer  of  the  liver.  The 
internal  carotid  was  obstructed  by  a  thrombus,  probably 
spontaneous,  since  no  embolus  was  found,  and  there  was 
fatty  and  calcareous  degeneration  of  the  wall  of  the  vessel. 
There  was  a  large  area  of  softening  in  the  left  hemisphere. 
The  ophthalmic  artery  was  patent,  evidently  by  a  collateral 
circulation  having  been  set  up.  The  vitreous  was  trans- 
parent, the  retina  thickened,  and  around  the  papilla  were  four 
opaque  white  spots,  which  were,  however,  found  to  be  due  to 
the  persistence  of  the  medullary  sheath  of  the  nerve  fibres. 
The  ganglion  cells  were  granular.  The  elements  of  the 


1  "Arch,  fiir  Ophth.,"  Bd.  xxxi.  p.  119,  PI.  3. 

2  A  case  is  recorded  by  Wurst,  for  instance  (Virchow's  "  Jahresbericht," 
1877,    ii.   463,   from   the    "  Przeglad  lekarski  "),  in  which   optic  neuritis, 
"  stauungs-papille,"  was  associated  with  cerebral  softening — a  spot  the  size 
of  a  walnut  in  the  posterior  portion  of  the  left  hemisphere,  and  a  second,  the 
size  of  a  bean,  in  the  pons  Varolii.     Sudden  complete  amaurosis  had  come  on 
a  few  days  before.     There  was,  however,  interstitial  nephritis  and  hypertrophy 
of  the  heart,  and  it  is  most  probable  that  the  optic  neuritis  was  due  to  the 
renal  disease.     In  the  remarkable  case  figured  in  PI.  VI.  2,  optic  neuritis  co- 
existed with   softening  from   extensive  arterial  disease,  the   results  of  old 
traumatic  meningitis,  but  inflammatory  (?)  growths  existed  beneath  two  old 
fractures  of  the  skull.     The  man  had  had  syphilis,  but  the  lesions  presented 
no  syphilitic  character. 

3  "Arch,  fur  Path.  Anat.,"  Bd.  x.  1856,  p.  189. 


154  MEDICAL    OPHTHALMOSCOPY. 

nuclear  layers  showed  a  tendency  to  arrange  themselves  in 
lobular  cylinders.  Another  case  of  the  same  character 
which  came  under  my  observation  has  been  before  alluded  to 
(p.  32),  and  in  it  the  ophthalmoscopic  changes  would  pro- 
bably have  been  much  more  striking.  Although  the  origin 
of  the  ophthalmic  artery  was  closed  by  clot,  the  central 
artery  of  the  retina  retained  a  channel,  narrowed  by  clot 
formed  upon  its  walls.  Some  retinal  branches  were  pervious, 
others  closed.  The  retina  presented  atrophy  of  all  its 
structures,  and  was  reduced  to  about  two-thirds  of  its 
normal  thickness. 

It  is  important,  therefore,  to  watch  the  fundus  continu- 
ously in  cases  of  thrombosis  in  the  region  of  the  internal 
carotid.  It  is  probable  that  the  obstruction  of  the  carotid 
would  always  be  accompanied  by  a  sudden  diminution  in 
the  size  of  the  retinal  artery,  the  degree  of  this,  and  the 
occurrence  of  parenchymatous  changes  in  the  retina,  depend- 
ing on  the  character  of  the  anastomoses  of  the  ophthalmic 
artery.  These  are  usually  abundant,  chiefly  with  the  facial, 
but  also  to  a  less  extent  with  the  middle  meningeal. 

Softening  from  Arterial  Thrombosis  due  to  Blood  States. — 
In  this  condition,  which  is  rare  except  in  the  puerperal 
state,  ophthalmoscopic  changes  have  been  found  only  in  cases 
of  septicaemia  (q.  v.). 

Softening  from  Venous  Thrombosis.  —  Ophthalmoscopic 
changes  are  unknown.  In  thrombosis  of  the  cavernous  sinus, 
it  is  said  that  there  may  be  double  optic  neuritis  and 
exophthalmos.  Slow  obliteration  of  this  sinus,  however, 
may  cause  no  ophthalmoscopic  changes. 

3.  PRIMARY  SOFTENING. — Primary  softening  of  the  brain 
is  still  a  region  of  cerebral  pathology  of  which  we  know  little. 
Apparently  three  forms  occur,  acute  and  subacute  inflamma- 
tory softening,  and  a  senile  form  of  chronic  softening. 

Inflammatory  Softening. — The  acute  form  is  only  known 
in  connection  with  injuries  in  which  meningitis  is  never 
absent,  and  ophthalmoscopic  changes  must  be  ascribed  to 
this  rather  than  to  the  morbid  process  in  the  brain. 


ABSCESS    OF    BRAIN.  155 

Subacute  Softening  is  a  possible  lesion,  symptoms  suggest- 
ing it  being  met  with  especially  in  gouty  persons,  but  no 
optic  neuritis  has  been  seen  in  connection  with  it — a  fact 
of  much  importance,  since  it  is  upon  this  and  upon  the 
occasional  retrogression  of  the  symptoms  that  the  hypo- 
thetical diagnosis  has  chiefly  rested. 

Chronic  Softening  is  a  certain  senile  lesion,  but  is  extremely 
rare.  A  few  cases  have  been  described,  but  in  this  the 
nature  of  the  malady  has  not  been  suspected  during  life. 
Apparently  it  is  not  attended  with  ophthalmoscopic 
changes. 

ABSCESS  OF  BRAIN. 

The  only  changes  known  are  consecutive.  Optic  neuritis, 
which  differs  in  no  respect  from  that  due  to  cerebral  tumour, 
is  found  in  many  cases :  the  papillae  are  swollen,  red,  and 
opaque,  the  vessels  concealed,  and  haemorrhages  may  be  pre- 
sent. But  the  neuritis  is  frequently  absent ;  the  rapidity  with 
which  the  abscess  develops  or  increases  being,  apparently,  the 
chief  element  in  the  disease  on  which  the  presence  of  neuritis 
depends.  This  element,  however,  is  merely  the  result  of  the 
intensity  of  the  inflammation  which  causes  the  abscess,  and 
so  we  trace  the  result  to  the  condition  which,  beyond  any 
other,  seems  to  determine  this  effect  of  a  cerebral  lesion, — the 
amount  of  irritation  produced  by  the  central  disease.  This 
condition,  however,  it  should  be  remembered,  is  subject  to 
another — that  of  time.  Several  days  are  necessary  for  the 
development  of  neuritis ;  sometimes,  indeed,  when  the 
morbid  process  is  in  a  distant  part  of  the  brain,  several 
weeks  may  be  required.  Hence  lesions  in  which  the  irrita- 
tive element  is  most  intense  often  end  the  life  of  the  patient 
before  their  effect  on  the  eye  can  be  produced. 

The  changes  in  the  optic  nerves  do  not  differ  from  those 
met  with  in  tumours,  &c.  Dropsy  of  the  sheath  has  not 
often  been  looked  for,  but  was  found  in  one  case  (Peipers), 
the  abscess  being  in  the  right  temporal  lobe. 

The   only   conspicuous    difference   between   the   cases   of 


156  MEDICAL   OPHTHALMOSCOPY. 

abscess  with,  and  those  without,  optic  neuritis,  is  that  due 
to  the  course  of  the  malady.  In  perhaps  the  larger  propor- 
tion of  the  cases  with  neuritis  the  bone  disease  causing  the 
abscess  was  the  result  of  injury.  In  two  instances  recorded 
by  Hughlings-Jackson  this  was  the  case.  The  position  of 
the  abscess  has  been  in  the  temporal  and  posterior  parts  of 
the  parietal  lobes  beneath  the  surface.  In  a  case  recorded 
by  Benedikt  it  was  outside  the  optic  thalamus.  Abscess  in 
the  left  hemisphere  of  the  cerebellum,  in  a  case  recorded  by 
Pfluger,1  caused  double  optic  neuritis,  well  marked,  with 
capillary  haemorrhages  on  the  papilla,  and  large  extra- 
vasations beyond  its  edge. 

TUMOURS  OF  THE  BRAIN. 

A.—  GROWTHS. 

Associated  Conditions. — Growths  may  occur  in  the  eye, 
of  the  same  nature  as  the  growth  in  the  brain,  but  such 
cases  are  not  common.  The  disc  shown  in  PI.  III.  4  is  the 
left  disc  of  a  boy,  whose  right  eye  was  the  seat  of  a  tuber- 
cular growth,  in  whose  brain  there  was  another  similar 
growth,  of  which  vomiting  and  optic  neuritis  were  the 
only  signs.  In  such  a  case  the  ocular  growth  becomes  an 
important  symptom.  Choroidal  miliary  tubercles  might 
be  expected  to  be  found  occasionally  in  cases  in  which  a 
tubercular  mass  exists  in  the  brain,  but  they  occur  rather 
in  acute  general  tuberculosis,  while  tubercular  tumours  of 
the  brain  are  rare  in  that  condition.  Their  nature  is  rather 
that  of  the  tubercular  condition  that  we  associate  with  the 
word  "  scrofula."  This  differs  in  course  and  associations 
from  acute  tuberculosis,  although  presenting  the  same  bacilli. 
Thus  choroidal  tubercles  are  met  with  far  more  frequently 
in  tubercular  meningitis  than  in  the  tubercular  growths. 

Consecutive  Changes. — Optic  neuritis  is  the  ocular  lesion  in 
intra-cranial  growths,  which  are,  on  the  other  hand,  its  most 
frequent  causes.  It  is  present,  in  various  degrees,  in  a  large 

1  "Arch.  f.  Ophth.,"  vol.  xxiv.  1878,  pt.  2,  p.  171. 


TUMOURS    OF    THE    BRAIN.  157 

proportion  of  the  cases  of  intra-cranial  tumour ;  in  what 
proportion  cannot  be  determined  by  statistics  from  published 
cases,  on  account  of  the  selection  for  publication  on  special 
grounds.  From  my  own  experience  I  should  say  that 
neuritis  occurs  in  about  four-fifths  of  the  cases.  This  is  a 
much  smaller  proportion  than  has  been  deduced  from 
published  cases.  Annuske  and  Reich,  for  instance,  collected 
eighty-eight  cases  with  ophthalmoscopic  examination  and 
autopsy,  and  found  that  there  was  no  ophthalmoscopic 
change  in  only  five  per  cent.  But  these  cases  have  all 
been  recorded  during  the  period  when  ophthalmoscopic 
observation  possessed  the  interest  of  novelty,  and  a  far 
larger  proportion  of  cases  with  neuritis  has  probably  been 
published  than  of  cases  without  neuritis. 

It  does  not  seem  possible  at  present  to  say  on  what  the 
occurrence  of  optic  neuritis  depends ;  why  it  is  present  in 
the  majority,  absent  in  the  minority.  Position  of  growth 
has  apparently  no  direct  influence  on  its  occurrence,  and 
only  an  indirect  influence,  insomuch  as  secondary  meningitis 
near  the  nerves  is  more  considerable  when  the  tumour  is  not 
far  from  that  part  of  the  base.  But  the  influences  through 
which  neuritis  is  caused  seem  to  be  exerted  from  any 
situation.  It  has  been  met  with  in  tumours  of  every  part 
of  the  cerebral  hemispheres,  of  the  pons  Yarolii,  the  crura 
cerebri,  the  cerebellum.  Tumours  of  the  medulla  below  the 
pons  usually  cause  death  too  quickly  for  optic  neuritis  to 
be  developed  ;  but  my  colleague,  Dr.  T.  Barlow,  has 
met  with  a  f  ca.se  of  neuritis  from  a  small  tumour  in  the 
middle  of  the  medulla  oblongata.  Allbutt  thinks  that 
.tumours  of  the  anterior  lobes  are  more  uniformly  attended 
with  neuritis  than  those  of  other  parts,  but  I  have  seen  a 
large  growth  in  the  anterior  hemisphere  with  normal  discs 
throughout. 

Nor  does  the  nature  of  the  tumour  apparently  influence 
the  development  of  neuritis.  It  occurs  with  every  variety — 
glioma,  sarcoma,  tubercle,  syphiloma.  The  most  frequent 
forms  of  tumour  are  those  which  are  most  usually  asso- 
ciated with  optic  neuritis ;  and  they  are  also  those  in  which 


158  MEDICAL   OPHTHALMOSCOPY. 

neuritis  is  most  frequently  absent — syphilomata,  tubercles, 
and  gliomata.  At  the  same  time,  growths  that  infiltrate 
and  only  damage  the  nerve  elements  late  in  time  and  little 
in  comparison  with  the  amount  of  the  growth,  seem  to  have 
less  tendency  to  cause  neuritis  than  those  which  damage 
readily.  A  like  difference — perhaps,  indeed,  related — is 
seen  from  the  amount  of  adjacent  inflammation  that 
is  produced.  The  greater  these  secondary  processes  about 
the  tumour,  the  more  readily  does  neuritis  occur.  Hence 
the  nature  of  a  growth  has  an  indirect,  though  not  a  direct, 
effect.  In  a  case  of  my  own,  of  a  glioma  infiltrating  almost 
the  whole  of  the  medulla  oblongata,  which  was  under  obser- 
vation for  two  months  before  death,  there  was  no  optic 
neuritis  at  any  time. 

The  size  of  the  tumour  also  seems  to  have  little  influence 
in  producing  neuritis.  I  have  twice  seen  syphilomata  the 
size  of  half  an  egg  without  optic  neuritis.  One  of  the  largest 
intra-cranial  tumours  I  have  met  with  was  a  sarcomatous 
growth,  the  size  of  the  closed  fist,  growing  from  the  dura 
mater,  and  compressing,  not  invading,  the  brain  over  the 
posterior  portion  of  the  parietal  lobe,  a  tumour  which  must 
have  increased  the  intra-cranial  pressure  as  much  as  it  is  ever 
increased  directly  by  a  growth,  and  in  this  case  the  discs, 
repeatedly  examined  from  soon  after  the  onset  of  the 
symptoms  until  death,  about  six  months  later,  were  perfectly 
normal;  and  a  similar  case  is  fully  described  by  Byrom 
Bramwell  in  his  recent  work  on  "  Intra-cranial  Tumours," 
pp.  11, 12.  On  the  other  hand,  Benedikt  has  recorded  a  case 
of  well-marked  neuritis  with  much  swelling  and  haemor- 
rhages, due  to  a  tubercle  of  the  pons  Yarolii  no  larger  than 
a  cherry.  There  were  no  signs  of  meningitis. 

The  chief  facts  at  present  known  regarding  the  mechanism 
by  which  optic  neuritis  is  produced  have  been  already  dis- 
cussed (p.  78).  Some  points  having  special  reference  to 
tumour  may  be  again  adverted  to.  It  is  clear  from  the  facts 
stated  above — and  a  long  list  of  similar  cases  might  be  given 
— that  encephalic  tumours  do  not  cause  neuritis  by  the  direct 
effect  of  their  mass  on  the  intra-cranial  pressure.  Perhaps 


TUMOURS    OF    THE    BRAIN.  159 

no  form  of  cerebral  tumour  is  attended  with  optic  neuritis 
in  a  larger  proportion  of  cases  than  glioma,  which  commonly 
does  not  press  upon,  but  invades,  the  brain  substance,  and 
often  occupies  the  invaded  tissue  almost  bulk  for  bulk. 

It  has  been  thought  that  the  rapidity  of  growth  of  a 
tumour  influences  the  occurrence  of  optic  neuritis,  but  a 
limited  experience  of  these  cases,  or  a  very  short  search 
among  recorded  cases,  disposes  of  the  hypothesis,  at  any  rate 
in  an  absolute  form.  Rapidity  of  growth  may  be  one  factor 
in  the  production  of  neuritis,  and  an  important  factor  in 
determining  the  rapidity  or  slowness  of  the  course  of 
the  neuritis,  but  it  certainly  does  not  alone  determine  its 
occurrence. 

There  is,  however,  one  mode  in  which  neuritis  is  produced 
which  may  sometimes  be  distinctly  traced  post-mortem,  viz., 
by  the  mechanism  of  meningitis.  The  disc  shown  in  PL 
III.  3,  for  instance,  was  in  a  case  of  tumour  originating  in 
the  pineal  body  and  invading  the  anterior  corpora  quadri- 
gemina.  The  changes  in  the  disc  were  very  gradual  in 
development,  and  moderate  in  degree.  There  was  no 
general  meningitis,  but  the  orbital  lobules  were  gently 
adherent,  and  fine  shreds  of  lymph  were  visible  on  the 
dura  mater  after  their  separation.  The  optic  nerves  in 
front  of  the  commissure  were  swollen  and  reddened. 
Microscopical  evidence  of  neuritis  of  the  nerve-trunk  was 
very  distinct.  In  another  case  of  tumour  (glioma)  of  the 
anterior  lobe,  in  which  the  neuritis  was  of  the  form  most 
characteristic  of  tumour,  greyish-red,  with  much  swelling, 
the  microscopic  changes  in  the  nerve-trunk,  most  intense 
behind  the  foramen,  indicated  a  communicated  descending 
neuritis,  and  old  adhesions  over  the  tumour  showed  that 
there  had  been  local  meningitis.  It  must  be  remembered 
that,  in  such  cases,  whatever  mechanism  leads  to  the  occur- 
rence of  neuritis  without  meningitis  may  influence  the 
degree  and  course  of  that  which  is  set  up  by  meningitis. 

In  most  cases  optic  neuritis  is  a  transient  event  in  the 
history  of  a  cerebral  tumour,  not  a  constantly-associated 
condition.  A  tumour  may  exist  and  cause  symptoms  for  a 


160  MEDICAL   OPHTHALMOSCOPY. 

considerable  time  without  leading  to  any  change  in  the  eyes, 
and  then  optic  neuritis  may  be  rapidly  developed,  run  its 
course,  and  pass  away,  in  many  cases  leaving  atrophy  of  the 
discs,  while  the  symptoms  of  the  tumour  continue  or  increase 
for  months  or  years.  It  is  not  only  that  a  tumour  takes  a 
certain  time  to  cause  optic  neuritis,  but  it  often  exists  for  a 
considerable  time  before  the  mechanism  for  the  production 
of  neuritis,  whatever  that  may  be,  is  set  in  operation.  A 
tumour  may  exist  and  cause  symptoms  for  years  before  optic 
neuritis  is  produced.  A  striking  instance  of  this  is  afforded 
by  a  case  which  was  under  the  care  of  Dr.  Hughlings- 
Jackson,  who  had  examined  the  eyes  repeatedly  during  nine 
months,  and  always  found  them  normal.  Then  neuritis 
came  on,  but  subsided,  and  in  six  weeks  the  discs  were  again 
normal,  and  continued  so  till  death.  The  microscopical 
appearance  of  part  of  the  papilla  is  shown  in  Fig.  22,  p.  63. 
Dr.  Jackson  has  recorded1  a  still  more  significant  case,  in 
which  a  man  had  had  symptoms  of  cerebral  tumour  for  nine 
years :  during  the  last  three  years  his  discs  had  been 
repeatedly  examined  and  found  normal.  Six  weeks  before 
death  neuritis  was  discovered. 

In  many  cases  in  which  neuritis  occurs  long  after  the 
symptoms  of  tumour  have  existed,  its  occurrence  precedes 
death  by  no  long  interval. 

The  appearance  of  the  discs  in  intra-cranial  tumour  is 
that  of  neuritis  in  its  most  typical  form,  as  described  in  a 
preceding  page  (p.  49).  The  neuritis  may  stop  at  one  or 
another  of  its  stages,  constituting  what  may  be  termed 
varieties  of  neuritis.  As  already  stated,  until  our  knowledge 
of  the  relation  of  the  appearances  to  their  causes  is  much 
more  extensive,  and  founded  on  more  minute  and  full 
observation  of  the  conditions  of  origin,  macroscopic  and 
microscopic,  a  division  of  neuritis  into  varieties  according  to 
its  degree  is  much  more  useful  than  a  separation  of  forms 
according  to  hypothetical  modes  of  origin.  Those  varieties 
or  stages  have  been  already  enumerated  (p.  93).  Each  of 
the  earlier  stages  may  or  inay'not  be  accompanied  by  obvious 
1  "  Med.  Times  and  Gazette,"  Sept.  4,  1875. 


TUMOURS   OF    THE    BRATN.  161 

over-distension  of  veins,  and  each  may  be  accompanied  by 
extravasations. 

The  neuritis  of  tumour  is  in  most  cases  double,  sometimes 
equally  advanced  in  the  two  eyes,  often  more  intense  and 
subsiding  earlier  in  one  than  in  the  other.  Rarely  the 
affection  of  the  disc  is  unilateral,  and  this,  although  the 
tumour  may  be  in  the  brain,  where  growths  commonly  cause 
double  neuritis.  In  two  cases  of  this  character  recorded 
by  Hughlings-Jackson,1  and  in  one  described  by  Field,2  the 
neuritis  was  on  the  side  opposite  to  the  tumour.  In  one 
recorded  by  Greenfield,3  however,  where  unilateral  neuritis 
accompanied  an  abscess  in  the  top  of  the  temporo-sphe- 
noidal  lobe,  the  neuritis  was  on  the  same  side  as  the  lesion. 
Possibly  the  inflammatory  process  extended  to  the  nerve  as 
it  passed  to  the  optic  foramen. 

Symptoms. — The  symptoms  of  the  neuritis  which  accom- 
panies cerebral  tumour  have  been  already  fully  described 
(p.  69) .  It  must  be  remembered  that  all  symptoms  may  be 
absent,  the  acuity  of  vision,  the  fields  of  vision,  and  colour- 
vision  may  also  be  unaffected,  as  in  many  of  the  cases 
figured  in  the  plates  and  referred  to  in  the  description  of 
the  symptoms  of  neuritis.  It  must  also  be  remembered  that 
affections  of  sight  of  various  kinds  may  co-exist  with 
neuritis,  and  be  due,  not  to  the  intra-ocular,  but  to  the 
intra-cranial  disease. 

Regarding  the  course  of  the  neuritis  in  cerebral  tumour,  it 
is  important  to  note  that  the  neuritis  often  coincides  at  its 
onset  with  an  obvious  increase  in  the  other  symptoms  of  the 
cerebral  tumour.  This  was  pointed  out,  long  ago,  by  Dr. 
Hughlings-Jackson.  Instances  of  it  are  frequent,  but  at  the 
same  time  exceptions  are  not  rare.  It  is  probably  true, 
however,  that  the  occurrence  of  optic  neuritis  indicates  progress 
in  the  morbid  growth  and  its  consequences. 

"With  regard  to  the  course  of  the  neuritis,  it  is  necessary  to 
distinguish  two  classes  of  cases.  One  of  these  is  where  the 

1  "Ophth.  Hosp.  Rep.,"  1871,  and  "  Brit.  Med.  Journal,"  July  20,  1872. 

2  "  Brain,"  July,  1881,  p.  247. 

3  "  Brit.  Med.  Journal,"  1886,  p.  317. 

M 


162  MEDICAL   OPHTHALMOSCOFY. 

progress  of  the  tumour,  either  spontaneously,  or  under  the 
influence  of  treatment,  becomes  lessened  or  arrested  after  the 
onset  of  the  neuritis;  the  other,  where  the  progress  of  the 
tumour  to  which  the  neuritis  is  due  is  uninterrupted. 

In  the  first  event,  the  neuritis  commonly  subsides.  It 
may  pass  away  completely,  even  although  it  has  reached  the 
stage  of  considerable  swelling  and  obscuration  of  disc  and 
vessels,  with  distended  veins  and  narrowed  arteries,  and 
sight  may  throughout  be  unimpaired.  This  occurred,  for 
instance,  in  the  cases  shown  in  PL  IV.  1,  2,  3,  4,  Y.  3.  Or, 
less  commonly,  a  slight  or  moderate  damage  to  sight,  from 
the  inflammatory  swelling  and  damage  to  nerve  fibres,  may 
pass  away.  Yery  frequently,  however,  although  the  neuritis 
subsides,  amblyopia  occurs  or  increases  when  the  nerve  fibres 
suffer  from  compression  from  the  contracting  tissue.  The 
last  is  the  more  likely  to  occur  the  longer  the  neuritis  has 
lasted,  because  there  is  then  more  tissue  formed,  incapable 
of  removal. 

Instances   of    each    course    are   often   seen   in   syphilitic 
tumours,  and  not  rarely  where  there   is   strong  reason   to 
believe  that  a  scrofulous  tumour  exists — a  cerebral  or  cere- 
bellar  tubercle.     In  cases  in  which  the  neuritis  is  slight  and 
commencing,  a  subsidence  of  the  neuritis  may  be  the  first 
sign  of  the  improvement.     It  was  so  in  the  case  figured  in 
PL  Y.  4,  in  which  the  neuritis  passed  away  before  there  was 
any  improvement  in  the   symptoms,  and  then   slowly  the 
paralysis  lessened,  and  improved  up  to  a  certain  point,  at 
which    it   became   stationary,   no  doubt   from   the   tumour 
(probably  tubercular)  ceasing  to  grow,  and  becoming,  from 
partial  degeneration,  smaller,  and  thus  permitting  damaged 
tissue  near  it  to  recover,  while  the  destruction,  which  had 
before  taken  place,  persisted.     In  syphilitic  tumours,  arrest 
can  be   obtained  much   more   rapidly    than    in   tubercular 
growths,  and  a  considerable  neuritis  may  pass  away  without 
damage  to  vision  (PL  IY.  1  &  2,  3  &  4,  VI.  4  &  5).     In 
these  cases,  however,  if  a  considerable  neuritis  exists  before 
the  treatment  affects  the  tumour,  tissue-changes  too  often 
progress  in  the  disc  to  an  extent  which  leads  to  loss  of  sight 


TUMOURS    OF    THE    BRAIN.  163 

even  though  ultimately  the  cerebral  lesion  ceases  to  increase 
and  becomes  quiescent  (PL  IV.  5,  6).  Occasionally,  although 
rarely,  an  analogous  arrest  of  growth  occurs  in  other 
tumours,  attended  with  degeneration  and  calcification.  The 
neuritis  may,  in  these  cases,  subside  with  the  change  in  the 
growth. 

In  the  cases  in  which  the  tumour  causing  the  optic  change 
continues  its  growth,  as  most  tumours  of  other  descriptions 
than  the  tubercular  and  syphilitic  growths,  the  course  of  the 
neuritis  differs  according  to  the  intensity  of  the  inflammation. 
When  this  is  considerable,  the  neuritis  remains  for  a  time 
at  its  height ;  commonly  the  signs  of  strangulation  are 
developed,  and  then  the  neuritis  subsides  slowly  into  atrophy. 
The  inflammation,  as  it  were,  terminates  itself,  and  its  con- 
sequences remain.  "When  the  neuritis  does  not  reach  so 
intense  a  grade  it  has  a  much  longer  duration.  The  lilac- 
grey  neuritis,  with  little  sign  of  strangulation,  may  persist 
for  months  without  much  change,  and  then  slowly  subside  to 
atrophy ;  sight  perhaps  being  little  damaged  until  the  sub- 
sidence, when  the  tissue  formed  during  the  long  duration  of 
the  inflammation  compresses  the  nerve-fibres.  In  a  still 
slighter  degree,  that  of  "  slight  neuritis,"  for  instance  (p.  93), 
the  change  may  persist  without  alteration  for  a  very  long 
time.  In  the  case  represented  in  PL  V.  Figs.  1  and  2,  the 
appearance  of  the  discs  was  unchanged  for  a  year  and  a 
half ,  and  when  the  patient  was  again  seen  a  year  later,  the 
neuritis  was  nearly  in  the  same  degree,  although  the  least 
inflamed  portion  of  the  disc  had  become  grey  and  sight  was 
gone. 

There  is  at  present  little  direct  information  regarding  the 
conditions  which  determine  the  course  and  duration  of 
neuritis  in  the  cases  in  which  the  cerebral  tumour  continues 
its  progress.  But  it  has  been  seen  that  the  onset  of  neuritis 
may  accompany,  or  succeed,  an  increase  in  the  symptoms 
due  to  the  tumour,  such  as  indicates  an  increase  in  the  size 
or  irritative  action  of  the  growth  itself.  And  we  have  seen 
also  that  the  early  subsidence  of  neuritis  may  attend  a 
diminution  in  the  other  effects  of  the  tumour  such  as  may 


164  MEDICAL    OPHTHALMOSCOPY. 

be  taken  as  indicative  of  an  arrest  of  growth,  or  even  a 
diminution  in  size.  These  facts  taken  together  indicate  that 
the  course  of  the  neuritis  is,  to  some  extent  at  least,  depend- 
ent on,  and  influenced  by,  the  course  of  the  tumour.  This 
conclusion  is  corroborated  by  the  fact  that  in  some  cases  of 
tumour  of  very  chronic  nature,  the  course  of  the  neuritis  is 
equally  chronic.  The  case  mentioned  above  (PL  V.  1  &  2) 
is  a  striking  illustration  of  this,  since  the  progress  of  the 
very  marked  symptoms  was  but  slight  during  the  year  and  a 
half,  in  which  the  neuritis  was  absolutely  stationary.  In 
rare  cases,  as  in  that  recorded  by  Field  and  above  referred 
to,  in  which,  without  retrogression  of  the  tumour,  neuritis 
subsides  without  influencing  vision,  the  affection  of  the  optic 
nerve  is  probably  largely  due  to  excessive  secondary  effects 
of  the  growth.  In  this  case  there  was  adjacent  softening 
out  of  all  proportion  to  the  size  of  the  growth  itself. 

Significance. — The  value  of  optic  neuritis  as  an  indication 
of  the  existence  of  an  intra-cranial  tumour  is  very  great. 
Tumour  is  the  cause  of  the  majority  of  cases  of  neuritis  due 
to  intra-cranial  disease.  On  the  other  hand,  neuritis  is 
present,  at  some  period,  in  at  least  four-fifths  of  the  cases 
of  tumour,  and  it  may  be  the  only  unequivocal  sign  of  the 
organic  intra-cranial  disease. 

It  is  important  to  remember  that  the  neuritis  is  a  transient 
condition,  however  long  its  duration,  and  that  its  effects 
continue  a  much  longer  time  than  the  inflammation.  The 
atrophy  left  by  neuritis  may  constitute  unequivocal  evidence 
of  the  antecedent  inflammation,  and  where  actual  atrophy 
is  not  left,  the  state  of  the  disc  and  the  narrowing  of  the 
vessels  may  show  clearly  that  there  has  been  previous 
neuritis.  Unfortunately  it  is  not  always  possible,  in  old- 
standing  cases,  to  say  from  the  aspect  of  the  discs  how  the 
atrophy  originated.  If  the  neuritis  was  moderate,  and  the 
adjacent  choroid  undisturbed,  a  clean  cut  disc  may  be  left, 
and  the  narrowing  of  the  vessels  may  not  be  greater  than 
is  sometimes  seen  in  cases  of  atrophy  of  the  disc  of  other 
forms.  The  concealment  of  the  lamina  cribrosa  is,  however, 
usually  complete.  Valuable  information  may  also  be  gained 


TUMOURS    OF    THE    BRAIN.  165 

from  the  circumstances  under  which  the  loss  of  sight  came 
on ;  the  existence  at  the  time  of  cerebral  symptoms  makes 
it  probable  that  the  atrophy  was  due  to  neuritis. 

It  is  not  only  during  life  that  neuritis  may  assist  the 
diagnosis  of  tumour.  As  an  instance,  I  may  mention  the 
case  of  a  man  who  died  soon  after  his  admission,  with  hemi- 
plegia,  into  University  College  Hospital.  The  autopsy  re- 
vealed a  soft  area,  bounded  and  crossed  by  trabeculse  of 
firmer  tissue,  which  was  at  first  thought  to  be  an  area  of 
old  softening  with  some  connective-tissue  formation  in  and 
about  it.  It  was  suggested,  however,  that  it  might  be  a 
tumour.  Before  it  was  examined  with  the  microscope,  the 
backs  of  the  eyes  were  removed,  and  found  to  present  distinct 
evidence  of  neuritis — swollen  papillae  with  haemorrhages. 
A  diagnosis  of  probable  tumour  was  therefore  made,  and 
was  fully  confirmed  by  the  microscope. 

From  the  facts  given  above  it  is  evident  that  optic  neuritis 
may,  in  some  cases,  afford  not  only  diagnostic,  but  prognostic 
indications.  A  subsidence  of  neuritis  which  has  not  reached 
any  considerable  degree  of  intensity,  may  be  taken  as  indicat- 
ing, in  most  cases,  a  retrogression  of  the  growth,  and  a  neuritis 
of  very  chronic  course  affords  evidence  that  the  progress  of 
the  tumour  is  equally  chronic.  It  might  be  supposed,  there- 
fore, that  the  absence  of  neuritis  would  indicate  still  greater 
ohronicity.  This,  however,  cannot  be  inferred,  since  tumours 
of  very  rapid  course  may  be  unattended  with  neuritis,  and 
it  is  only  when  neuritis  is  actually  present  that  a  prognostic 
inference  can  be  drawn. 

It  has  been  remarked  that  optic  neuritis  in  tumour  of  slow 
growth  often  occurs  not  long  before  death.  In  such  cases, 
also,  it  affords  some  prognostic  indication.  In  more  acute 
cases,  or  in  those  in  which  it  developes  early,  it  has  not  the 
same  significance.  It  would  appear  as  if  the  mechanism  for 
the  production  of  neuritis  were,  in  the  latter  cases,  readily 
excited,  while  in  the  former  it  is  the  result  of  changes  of  such 
a  degree  as  to  be  incompatible  with  the  long  continuance  of 
life. 


166  MEDICAL    OPHTHALMOSCOPY. 

Simple  atrophy  of  the  optic  nerves  also  results  from  intra- 
cranial  tumours,  but  only  by  the  mechanism  of  compression 
of  the  fibres  of  the  optic  nerve  where  all  those  proceed- 
ing from  one  eye  or  both  can  be  destroyed.  Thus,  such 
atrophy  only  occurs  when  there  is  pressure  on  the  chiasma, 
or  on  one  of  the  nerves  in  front  of  the  chiasma.  Pressure 
on  one  tract  seldom  causes  sufficient  alteration  in  the  disc 
to  be  attended  wi.th  more  than  slight  pallor  and  slight 
shrinking  in  both  eyes.  Theoretically,  pressure  on  both 
tracts  should  cause  conspicuous  atrophy,  but  no  instance 
is  known  ;  perhaps  life,  in  such  a  case,  is  not  prolonged 
for  the  time  necessary  to  permit  visible  alteration.  The 
simple  atrophy  is  thus  "  secondary "  in  nature,  and  due 
to  the  direct  effect  of  the  growth  on  the  fibres  of  the 
nerves,  and  also  to  the  secondary  consequences  of  the 
tumour — especially  the  pressure  of  ventricular  effusion  on 
the  chiasma.  It  is  doubtful  whether  this  form  of  atrophy 
ever  results  from  the  damage  to  the  nerve  by  inflammation, 
such  as  may  be  produced  by  a  secondary  meningitis.  In 
tumours,  the  tendency  for  a  communicated  inflammation  to 
spread  down  the  nerve  is  so  strong  that  optic  neuritis  seems 
to  be  invariable.  But  the  visible  inflammation  is  often 
slighter  than  the  failure  of  sight,  and  the  ultimate  atrophy 
may  be  in  part  simple  although  apparently  papillitic.  Such 
atrophy  has  the  characters  of  secondary  atrophy  of  the  optic 
nerves,  the  features  and  origin  of  which  have  been  already 
described.  Great  caution  is  also  necessary  in  inferring,  from 
the  appearance  of  discs  long  after  the  onset  of  the  atrophy, 
that  this  was  simple  and  not  neuritic.  We  have  already 
seen  that  the  characters  of  the  latter  may  ultimately  resemble 
very  closely  those  of  the  former.  Moreover,  not  only  may 
there  be  a  combination  of  the  two  processes  (secondary 
atrophy  from  greater  damage  near  the  chiasma,  and  the 
atrophy  from  papillitis),  but  the  two  may  occur  at  different 
periods.  The  chiasma  may  be  compressed  by  ventricular 
effusion,  or  even  by  a  fresh  increase  in  the  tumour,  after 
neuritis  has  gone  on  to  partial  atrophy.  Sight,  damaged 
much  or  little  by  the  neuritic  process,  may  fail  rapidly  at  a 


TUMOURS    OF    THE    BRAIN.  167 

subsequent  period  from  secondary  pressure  effects.  This 
was  well  illustrated  in  the  case  of  a  man  who  was  admitted 
with  double  optic  neuritis,  impairment  of  vision,  and  symp- 
toms pointing  to  a  tumour  of  the  base  involving  the  ocular 
nerves.  Under  treatment  with  iodide,  the  neuritis  quite 
subsided,  and  vision  improved  until  it  became  almost 
normal,  with  perfect  fields.  Nine  months  later,  however, 
deterioration  of  sight  again  occurred,  the  fields  remaining 
normal,  but  nothing  could  be  detected  with  the  ophthalmo- 
scope. Six  months  after  the  relapse  he  had  a  foetid  smell 
in  the  left  nostril  and  loss  of  vision  in  the  temporal  half 
of  the  right  field.  A  few  months  later  there  was  failure 
of  sight  in  the  temporal  half  of  the  left  field,  and  there 
were  also  indications  of  pressure  on  the  right  fifth  and 
left  third  nerves.  He  was  under  observation  for  five  years 
later,  during  which  time  most  of  the  symptoms  passed  off. 
There  was,  however,  atrophy  of  both  discs,  with  qualitative 
perception  of  light  only,  and  complete  loss  of  the  sense  of 
smell.  There  must,  in  this  case,  have  been  a  tumour  at 
the  base  of  the  brain,  pressing  on  the  anterior  part  of  the 
chiasma,  and  also  involving  the  nerves  mentioned. 

E.-HYDATID  CYSTS. 

Associated  Changes. — A  cysticercus  has  been  occasionally 
observed  in  the  vitreous  humour,  but  the  coincidence  of  a 
parasite  in  the  eye  with  symptoms  of  cerebral  tumour  due 
to  another  in  the  brain,  has  not,  I  believe,  hitherto  been 
recorded. 

Consecutive  Changes. — Optic  neuritis  is  frequent  in  cases  of 
hydatid  disease  of  the  brain,  and  has  all  the  characters  of  the 
neuritis  which  occurs  in  growths — swollen  papilla,  obscured 
and  tortuous  vessels,  haemorrhages.  It  has  been  observed 
with  hydatid  cyst  of  both  cerebrum  and  cerebellum.  It  may 
go  on  to  consecutive  atrophy,  life  being  prolonged  for  years. 
The  few  cases  on  record  of  neuritis  associated  with  cysts  in 
the  brain,  the  nature  of  which  was  not  ascertained,  were 
probably  examples  of  hydatid  disease. 


168  MEDICAL    OPHTHALMOSCOPE. 


LABIO-GTLOSSAL  PARALYSIS. 

In  chronic  bulbar  paralysis,  due  to  degeneration,  ophthal- 
moscopic  changes  are  extremely  rare.  Unilateral  atrophy 
•was  once  seen  by  Gralezowski,  and  Robin  quotes  a  case  from 
Dianaux  of  rapid  atrophy  of  both  nerves  in  the  course  of  the 
affection  in  a  man  aged  sixty-seven.  It  was  accompanied  by 
transient  paralysis  of  one  sixth  nerve.  Sight  was  lost  com- 
pletely in  two  months,  but  considerable  subsequent  restoration 
of  vision  (up  to  TV)  occurred. 

INTRA-CRANIAL  ANEURISM. 

Miliary  aneurisms  have  been  spoken  of  in  connection  with 
cerebral  haemorrhage.  Intra-cranial  aneurisms  of  larger 
size  are  not,  as  a  rule,  accompanied  by  any  associated  ocular 
changes:  those  of  the  central  artery  of  the  retina  being  too 
rare  to  be  of  significance.  Nor  do  they  often  cause  consecutive 
changes,  unless  their  position  is  such  as  to  press  upon  the  optic 
nerve  (causing  unilateral  amaurosis  and  secondary  atrophy), 
on  the  chiasma  (bilateral  atrophy),  or,  very  rarely,  on  the  optic 
tract  (causing  hemianopia).  An  aneurism  of  the  internal 
carotid  may  obstruct  the  cavernous  sinus,  and  cause  transient 
distension  of  the  retinal  veins,  without  papillary  changes,  but 
the  pressure  is  relieved  by  the  free  communication  of  the 
ophthalmic  and  facial  veins  ;  the  enlarged  angular  vein  may 
be  conspicuous  beneath  the  skin.  In  rare  cases,  however,  an 
aneurism  in  this  situation  has  led  to  optic  neuritis,  as  in 
a  case  recorded  by  Michel ; x  double  neuritis,  with  evidence 
of  obstruction,  was  the  first  sign  of  a  cirsoid  aneurism  of  the 
two  internal  carotids.  It  pressed  on  the  optic  nerves  at  the 
spot,  and  these  showed  evidence  of  interstitial  inflamma- 
tion. Holmes  of  Chicago  has  recorded  several  cases  in 
which  optic  neuritis  co-existed  with  intra-cranial  bruit,  and 
in  the  only  one  on  which  a  post-mortem  was  obtained  an 

1  "Arch.  f.  Ophth.,"  xxxiii.  2,  p.  225. 


INTERNAL    HYDROCEPHALTJS.  169 

aneurism  of  the  internal  carotid  was  found ;  but  there  was 
also  an  adjacent  growth  in  the  pituitary  body. 

In  an  interesting  case1  (by  Jeaffreson  of  Newcastle-on- 
Tyne),  although  there  was  no  post-mortem  examination,  an 
aneurism  of  the  internal  carotid  was  most  probable,  and  caused 
unilateral  papillitis.  A  loud  intra-cranial  murmur  could  be 
arrested  by  compression  of  the  carotid ;  there  was  paralysis 
of  the  third  nerve,  and  subsequently  aphasia  developed. 

The  origin  of  the  papillitis  in  these  cases  is  probably  a 
descending  inflammation,  extending  to  the  nerve  from  that 
which  always  exists  around  an  aneurism.  That  the  papillitis 
is  not  the  effect  of  compression  of  the  cavernous  sinus  is 
probable  from  the  fact  that  aneurisms  which  produce  the 
same  effect  on  the  sinus  may  or  may  not  be  accompanied  by 
papillitis.  Moreover,  when  there  is  papillitis  the  enlarged 
communications  with  the  facial  vein  may  (as  ia  Jeaffreson's 
case)  afford  the  same  evidence  of  relief  to  mechanical  ob- 
struction, which  is  supposed  to  prevent  the  papillitis  (when 
this  is  absent)  by  those  who  ascribe  it  to  the  mechanical 
influence  alone. 

INTERNAL  HYDROCEPHALUS. 

Simple  internal  hydrocephalus,  without  a  growth,  is  not 
at  first  attended  by  ophthalmoscopic  changes  unless  the  state 
is  due  to  inherited  syphilis.  They  may  be  absent  through- 
out, even  though  the  distension  of  the  ventricles  is  such  as 
to  cause  a  marked  increase  in  the  size  of  the  head.  Some- 
times there  is  slight  fulness  of  the  retinal  veins.  Sight 
often  fails  at  a  later  period,  and  in  some  cases  early,  and 
the  signs  of  simple  white  atrophy  of  the  optic  nerve  are 
then  present.  In  several  cases  the  onset  of  the  atrophy  has 
been  watched,  and  the  occurrence  of  any  neuritic  process 
excluded.  In  a  few  cases  the  atrophy  has  been  preceded 
by  signs  of  neuritis  similar  to  that  seen  in  tumour;  it  is 
usually  slight  in  degree,  but  was  considerable  in  a  case 
recorded  by  Wildbrand  and  Binswanger.2 

1  "The  Lancet,"  March  8,  1879. 

2  "Centralbl.  f.  med.  Wiss.,"  1879,  p.  923. 


170  MEDICAL    OFHTHALMOSCOPY. 

The  simple  atrophy  of  the  nerves  is  usually  due  to  the 
pressure  of  the  distended  third  ventricle  on  the  optic 
chiasma.  In  one  adult  case,  mentioned  by  Forster,  the 
distended  ventricle  appeared  at  the  base  of  the  brain  as  a 
bladder  measuring  ten  lines  by  eight. 

It  has  been  said  by  Bouchut  that  the  ophthalmoscopic 
changes  may  serve  to  distinguish  chronic  hydrocephalus 
from  the  large  head  of  rickets;  but,  owing  to  the  lateness 
of  the  optic  changes,  the  cases  must  be  very  rare  in  which 
the  nature  of  the  disease  is  not  distinct  long  before  ophthal- 
moscopic signs  are  present. 


DISEASES  OF  THE  MEMBRANES  OF  THE 
BRAIN. 

MENINGEAL  GROWTHS. 

Tumours  springing  from  the  pia  mater  always  involve 
the  cerebral  substance  to  a  greater  or  less  extent,  either  by 
invasion  or  compression,  and  their  effects  have  been  included 
in  the  account  of  the  cerebral  tumours. 

Tumours  springing  from  the  dura  mater  differ  in  their 
effects  according  to  two  characteristics — first,  their  tendency 
to  invade  ;  secondly,  their  position,  whether  at  the  base  of 
the  brain  or  on  the  convexity.  They  commonly  cause  the 
same  effects,  in  the  brain  and  OD  the  eye,  as  growths  in  the 
brain  itself. 

Growths  springing  from  the  dura  mater  of  the  base  of  the 
brain  cause  optic  neuritis  much  more  frequently.  When  in 
the  front  of  the  base,  the  inflammation  around  the  growth 
may  extend  directly  to  the  nerve.  But  when  more  distant, 
as  in  the  posterior  fossa,  optic  neuritis  is  still  a  frequent  con- 
sequence and  is  often  intense,  even  when  the  nerve  centres  are 
not  invaded.  Those  that  invade  the  brain  have  the  same 
tendency  to  cause  optic  neuritis  as  tumours  beginning  in 
the  brain  substance.  But  the  compressing  growths  have 
this  tendency  in  far  slighter  degree,  and  it  is  less  the 
slower  the  growth  of  the  tumour.  The  more  rapidly  the 


MENINGITIS.  171 

pressure  is  induced,  the  greater  and  more  acute  is  the 
secondary  inflammatory  process  in  the  compressed  part, 
manifested  by  its  softening.  With  very  slowly  growing 
tumours  such  softening  may  be  entirely  absent,  and  the 
tendency  to  the  occurrence  of  optic  neuritis  is  very  much 
slighter.  I  have  seen  a  tumour  the  size  of  the  closed  fist, 
which  had  compressed  the  hinder  half  of  one  hemisphere  so 
as  to  produce  a  depression  corresponding  to  the  growth,  in 
which  there  was  no  optic  neuritis  up  to  the  end,  and  no  sign 
that  optic  neuritis  had  ever  existed.  Hence  the  absence  of 
optic  neuritis  is  evidence  of  some  value  that  a  tumour  at  the 
surface  of  the  brain  springs  from  the  membranes  and  is  not 
invasive.  Cases  are  on  record,  moreover,  in  which  the  optic 
neuritis  was  for  a  long  time  the  only  symptom  of  such  a 
growth ;  as  in  one  case  in  which,  after  the  neuritis  had 
existed  for  months,  hemiplegia  came  on,  and  was  found  to 
be  due  to  a  sarcoma  springing  from  the  periosteal  dura 
mater,  and  which  had  compressed  the  left  hemisphere  of  the 
cerebellum  and  the  left  side  of  the  pons  Yarolii.1  In  the 
case  figured  in  PI.  V.  5,  optic  neuritis,  although  not  the 
earliest  symptom,  reached  its  height  before  any  motor 
paralysis  occurred.  The  tumour  sprang  from  the  dura 
mater,  and  had  compressed  the  right  side  of  the  pons  and 
right  hemisphere  of  the  cerebellum. 

In  some  of  these  cases  secondary  meningitis  may  be  traced 
along  the  base  of  the  brain.  Such  inflammation  is  produced 
by  meningeal  growths  even  more  frequently  than  it  is  by 
tumours  in  the  substance  of  the  brain,  and  it  may  play  an 
important  part  in  the  production  of  the  changes  in  the  eye. 


MENINGITIS. 

The  effects  of  meningitis  on  the  eye  vary  much  according 
to  its  seat,  being  slight  and  late  when  the  inflammation  is 
at  the  convexity  of  the  hemisphere,  considerable  and 

1  Pagenstecher  and  Genth's  "Atlas  of  the  Path.  Anat.  of  the  Eyeball," 
PI.  xxxiv.  Fig.  3. 


172  MEDICAL    OPHTHALMOSCOPY. 

early  when  the  meningitis  is  at  the  base.  In  some  cases, 
especially  of  the  former  class,  ophthalmoscopic  changes  are 
entirely  absent,  and  when  present  they  attend  the  stage  of 
developed  inflammation  rather  than  the  initial  vascular 
disturbance.  They  thus  afford,  as  Manz  and  others  have 
pointed  out,  little  support  to  the  doctrine  that  the  intra- 
ocular circulation  shares  and  reveals  disturbances  of  the 
encephalic  vessels.  It  will  be  convenient  to  consider  sepa- 
rately the  changes  in  the  several  forms  of  meningitis. 

SIMPLE  MENINGITIS. — Acute  simple  meningitis  of  the 
convexity  is  usually  unaccompanied  by  ophthalmoscopic 
changes ;  only  when  it  has  lasted  for  a  considerable 
time  is  neuritis  sometimes  developed.  In  a  case  of 
purulent  meningitis,  suppurative  inflammation  of  the  eye 
(chemosis  and  post-mortem  infiltration  of  the  retina  with 
pus)  was  observed  by  Berthold,1  but  was  probably  coincident. 
Leube 2  has  recorded  a  case  of  purulent  meningitis  of  the 
convexity  secondary  to  septicaemia  in  which  there  was 
intense  inflammation  of  the  optic  nerve  in  front  of  the 
commissure.  The  only  changes  in  the  eye  were  distension 
of  the  retinal  veins  and  haemorrhages.  I  have  seen  well- 
marked  neuritis  in  a  case  of  septic  meningitis  (post- 
puerperal)  with  grave  cerebral  symptoms.  The  patient 
recovered. 

Chronic  simple  meningitis  of  the  convexity,  slight  in 
degree  (such  as  that  of  which  traces  are  often  found  in  the 
brains  of  drunkards),  is  also  commonly  unattended  by  any 
optic  change.  The  slight  oedema  and  congestion  of  the 
disc,  sometimes  seen  in  chronic  alcoholism,  'is  probably  the 
result  of  the  toxaemic  condition  rather  than  of  the  encephalic 
change. 

Simple  meningitis  of  the  base  is  rare,  except  in  association 
with  tumour  or  some  bone  disease.  Optic  neuritis  may  occur 
by  direct  propagation,  and  in  those  cases  in  which  the 
disease  is  chronic,  the  visible  changes  in  the  disc  may  be 

1  "Arch.  f.  Ophth.,"  Bd.  xvii  1874. 

2  "  Deut.  Arch.  f.  klin.  Med. ,"  1878,  xxii.  263. 


MENINGITIS.  173 

considerable  in  degree  and  duration.     Basilar  meningitis  is, 
however,  in  most  cases  tubercular  or  syphilitic. 

TUBERCULAR  MENINGITIS  :  Associated  Condition. — Tubercles 
of  the  choroid  may  now  and  then  be  found  in  tubercular 
meningitis,  and  furnish  valuable  diagnostic  information. 
But  they  are  less  frequent,  as  Cohnheim  pointed  out,  in 
tubercular  meningitis  than  in  general  tuberculosis  without 
meningitis.  Heinzel1  never  saw  them  in  forty-one  cases  of 
tubercular  meningitis  which  he  examined  with  the  ophthal- 
moscope, and  the  case  figured  (Fig.  49)  was  the  sole  instance 
in  which  they  were  found  in  twenty-six  cases  examined  by 
Grarlick  at  the  Hospital  for  Sick  Children.  The  few 
recorded  cases  in  which  neuritis  due  to  meningitis  co- 
existed with  tubercles  of  the  choroid  have  been  collected 
by  Bruckner. 2 

Consecutive  Changes. — A  peculiar  marbled  reflection  from 
the  retina  has  been  described  by  Leber  and  Hock,  occurring 
especially  in  the  neighbourhood  of  the  veins.  They  have 
seen  it  in  conjunction  with  tubercles  of  the  choroid,  and 
state  that  it  is  not  due  to  neuritis  occurring  earlier. 
Nevertheless,  redness  of  the  disc  is  sometimes  observed  in 
association  with  this  condition.  3  A  somewhat  similar  reflec- 
tion, chiefly  around  the  disc,  has  been  described  by  Manz 
as  the  most  frequent  change.  He  associates  it  with  oedema 
of  the  sheath  of  the  optic  nerve,  and  it  may  be  due  to 
a  slight  oedema  of  the  retina  (compare  PI.  I.  3). 

Changes  in  the  optic  discs  of  more  considerable  degree 
are,  however,  present  in  tubercular  meningitis  in  such  a 
proportion  of  the  cases  as  to  constitute  a  very  important 
symptom  of  the  disease.  The  frequency  of  the  occurrence 
has  been  variously  stated.  The  discs  are  often  normal 
throughout  in  the  rare  cases  in  which  the  tubercular 

1  "  Jahrbuch  fur  Kinderheilkunde,"  1875,  p.  334. 

2  "Arch.  f.  Ophthal.,"  vol.  xxvi.  pt.  3,  1880,  p.  154. 

3  It  is  doubtful  whether  this  appearance  is  really  pathological ;  a  condition 
very  like  it  is  met  with  apart  from  disease,  often   called  the  "watered-silk 
retina."     For  an  explanation  of  this  appearance,  see  Gunn,  "  Ophth.  Hosp. 
Rep.,"  vol.  xi.  p.  348. 


174  MKDICAL    OPHTHALMOSCOPY. 

inflammation  is  confined  to  the  convexity  of  the  brain.  In 
some  cases  of  basal  meningitis,  also,  changes  are  entirely 
absent.  Grarlick,1  of  twenty-six  cases  carefully  watched  at 
the  Children's  Hospital,  found  the  discs  normal  throughout 
in  five ;  distinct  swelling  was  developed  in  about  half  the 
whole  number,  increased  redness  only  in  one  quarter,  and 
in  a  few  others  only  distension  of  veins.  In  many  of  these 
cases,  however,  the  changes  were  slight,  and  their  patho- 
logical character  was  recognizable  only  by  their  development 
under  observation.  It  is  probable,  then,  that  considerable 
changes  are  present  in  one-half  the  cases,  and  that  in 
two-thirds  of  the  remainder  slight  alterations  will  be  found, 
if  the  discs  are  watched  with  care  from  day  to  day.  The 
occurrence  of  congestion  and  oedema  of  the  disc  seems  to  be 
especially  related  to  the  occurrence  of  inflammation,  and  the 
formation  of  lymph,  in  the  anterior  part  of  the  base,  about 
the  chiasma  and  the  optic  nerves. 

The  degree  of  change  is  rarely  great.  The  disc  becomes 
full-coloured,  and  its  outlines  hazy.  Sometimes  this  and 
distended  veins  constitute  the  only  morbid  appearance. 
More  often  swelling,  with  undue  striation,  becomes  visible 
on  direct  examination,  and  the  edges  of  the  disc  gradually 
cease  to  be  recognizable.  The  disc  has  sometimes  a  reddish- 
grey  aspect.  In  several  recent  cases  I  have  noted  that  the 
colour  of  the  swollen  papillae  was  much  paler,  especially  on 
examination  by  the  indirect  method,  than  in  the  early  stage 
of  the  acute  neuritis  of  cerebral  tumour ;  the  aspect  suggest- 
ing the  idea  of  a  subsiding  neuritis  rather  than  one  that  is 
commencing,  and  this  in  cases  in  which  the  neuritis  was 
quite  recent.  The  neuritis  rarely  passes  into  a  more  intense 
degree,  perhaps  because  life  is  only  prolonged  sufficiently  in 
cases  in  which  the  inflammation  is  not  intense.  The  veins 
are  often,  though  not  always,  over-distended  from  the  first. 
In  Grarlick's  observations  their  distension  was  especially 
related  to  excess  of  subarachnoid  fluid ;  when  the  quantity  of 
this  was  normal,  there  was  no  distension  of  the  sheath — a 
fact  of  much  importance.  Occasionally  white  lines  along 
1  "Med.-Chir.  Trans,"  1879,  p.  441. 


MENINGITIS.  175 

the  sides  of  the  vessels  are  unduly  conspicuous.  Haemor- 
rhages are  rare. 

Sometimes  white  spots  are  seen  in  the  neighbourhood  of 
the  swollen  disc.  They  are  in  the  substance  of  the  retina, 
and  consist  of  an  accumulation  of  lymphoid  corpuscles  in 
the  nuclear  and  molecular  layers,  or  of  degeneration  of 
nerve-fibres.  They  may  readily  be  mistaken  for  tubercles 
of  the  choroid.  It  has  been  thought  that  they  are  of  the 
nature  of  tubercles,  and  they  have  accordingly  been  described 
as  retinal  tubercles,  but  very  similar  spots  are  seen  in  neuro- 
retinitis  from  other  causes.  Occasionally  a  gauze-like  opacity 
is  seen  over  a  wide  area  of  the  retina,  with  scattered  white 
points  and  flakes  (Heinzel).  Very  rarely  retinal  haemor- 
rhages are  associated  with  the  papillitis.1 

The  changes  that  occur  in  tubercular  meningitis  are 
always  double,  though  often  more  advanced  on  one  side 
than  on  the  other.  In  some  cases  the  excess  was  found  by 
Garlick  to  be  on  the  side  of  the  chief  cerebral  change,  but  in 
a  few  it  was  on  the  other  side.  In  most  cases  the  patients 
die  not  long  after  its  development,  and  sight  suffers  little. 
In  the  rare  cases  that  recover  the  inflammation  does  not 
become  intense  within  either  the  skull  or  the  eye.  In  such 
cases  the  optic  neuritis  is  of  extreme  diagnostic  importance. 
As  the  cerebral  symptoms  subside,  the  neuritis  passes  away, 
and  sight  is  preserved  or  restored.  This  has  been  pointed 
out  by  Clifford  Allbutt,  and  two  probable  instances  are 
described  by  Grarlick.  The  symptoms  were  headache, 
vomiting,  constipation,  irregular  pulse,  normal  temperature, 
and  the  development  of  ophthalmoscopic  changes  under 
observation.  In  both  cases  recovery  was  complete.  In 
another  case  observed  by  him  an  increase  in  pulmonary  symp- 
toms was  attended  by  a  marked  decrease  in  the  cerebral 
symptoms,  and  in  the  optic  changes,  for  five  days  before 
death. 

Cases  of  optic  nerve  atrophy  of  old-standing  are  occa- 
sionally seen  in  which  sight  was  lost  in  early  life  with 
acute  cerebral  symptoms  very  like  those  of  an  attack  of  tuber- 
1  Heinzel,  loc.  cit.  p.  341,  Cases  6,  16,  19,  26. 


176  MEDICAL    OPHTHALMOSCOPY. 

cular  meningitis.  Several  such  cases  have  been  related  by 
Hutchinson.1  Incipient  atrophy  was  noted  by  Heinzel  in 
one  case  of  long  duration,  and  in  two  others  he  observed  the 
initial  stage  of  consecutive  atrophy.  In  some  of  the  cases  of 
recovery  from  supposed  tubercular  meningitis  with  ophthal- 
moscopic  changes,  the  symptoms,  it  must  be  remembered, 
may  possibly  have  been  due  to  a  tubercular  mass  in  the 
brain.  The  symptoms  of  such  a  tumour  sometimes  resemble 
closely  those  of  tubercular  meningitis,  but  much  more 
frequently  pass  away. 

The  neuritis  which  accompanies  tubercular  meningitis  was 
regarded  by  v.  Grraefe  as  affording  the  typical  example  of 
descending  neuritis,  the  inflammation  passing  directly  from 
the  membranes  to  the  optic  nerves.  With  this  my  own 
experience  accords.  In  some  cases  the  existence  of  inflam- 
mation in  the  trunk  of  the  nerve  is  obvious  on  naked-eye 
examination.  The  nerve  is  swollen,  softened,  and  reddened. 
In  most  cases  the  descending  neuritis  may  be  demonstrated 
by  microscopical  examination. 

Besides  the  distension  of  the  sheath,  which  sometimes,  but 
not  always,  coincides  (and  has  been  supposed  to  be  the  cause 
of  the  neuritis),  more  pronounced  lesions  are  often  found 
in  it.  The  sheath  usually  presents,  under  the  microscope, 
evidences  of  inflammation  and  exudation,  which  were  found 
by  v.  Ziemssen2  to  extend  from  the  chiasma  to  the  eye. 
Moreover,  Michel,3  in  a  case  in  which  there  was  a  cloudy 
halo  around  the  papilla,  found  not  only  effusion  into  the 
sheath,  but  numerous  miliary  tubercles  in  both  the  dural 
sheath  and  pial  tissue. 

In  a  considerable  number  of  cases  the  symptoms  of  menin- 
gitis are  distinct  before  the  ocular  changes  are  developed. 
In  such  cases  the  ophthalmoscope  corroborates  rather  than 
assists  the  diagnosis.  But  in  some  cases  the  cerebral  symp- 
toms are  latent  or  dubious,  and  in  these  the  examination  of 
the  eyes  may  afford  very  valuable  help,  and  it  is  probable 

1  "  Ophth.  Hosp.  Rep.,"  v.  310  and  ix.  124. 

2  "Jahrb.  f.  Ophthalmologie,"  1878,  p.  242. 

3  "Deutsch.  Archiv.  f.  klin.  lied.,"  xxxii.  p.  439. 


MENINGITIS.  177 

that  it  would  do  so  in  at  least  one-third  of  the  cases.  Of 
the  twenty-six  cases  watched  by  Garlick,  the  ophthalmoscope 
was  of  real  diagnostic  assistance  in  six,  and  would  doubtless 
have  been  so  in  a  larger  number  had  earlier  examination 
been  practicable.  In  one  case,  which  lasted  twenty-six 
days,  the  other  symptoms  were  indefinite  until  the  nine- 
teenth day,  but  on  the  fourteenth  day  the  ophthalmo- 
scopic  changes  were  so  unmistakable  that  the  diagnosis  of 
meningitis  was  confidently  made.  In  another  case,  ophthal- 
inoscopic  changes  were  distinct  on  the  ninth  day,  the  symp- 
toms were  diagnostic  only  on  the  fifteenth  day,  the  patient 
dying  on  the  twentieth  day.  In  both  cases,  the  changes 
about  the  optic  commissure  were  much  more  marked  than 
those  elsewhere. 

During  the  course  of  meningitis  a  diminution  of  the 
cerebral  symptoms  may  be  accompanied  by  a  diminution  in 
the  ocular  changes. 

SYPHILITIC  MENINGITIS. — Syphilitic  meningitis  (1)  may 
be  associated  with  the  ocular  signs  of  syphilis,  and  (2)  may 
cause  optic  neuritis.  When  at  the  base,  the  ophthalmoscopic 
signs  are  similar  to  those  of  tubercular  meningitis,  but  more 
chronic  in  course  and  more  considerable  in  degree.  When 
localized  in  the  convexity,  ocular  symptoms  may  be  entirely 
absent.  If  the  case  is  not  subjected  to  proper  treatment, 
and  local  chronic  meningitis  persists,  it  is  probable  that  the 
disc  sometimes  passes  into  a  condition  of  intense  neuritis, 
similar  to  that  which  is  seen  in  cerebral  tumour.  Syphilitic 
meningitis  is  a  malady  about  which,  however,  we  still  have 
much  to  learn.  Its  diagnosis  from  gummata  is  only  possible 
hy  the  more  extensive  symptoms,  and  a  growth  can  never 
be  excluded  if  focal  symptoms  are  produced.  Moreover,  the 
two  processes  pass  one  into  the  other. 

H^EMORRHAGIC     PACHYMENINGITIS     (H^EMATOMA      OF     THE 

DURA  MATER).  —  According  to  Flirstner,1  there  may  be 
mechanical  congestion  of  the  retinal  veins  and  papillitis, 

'*  "Arch.  f.  Psychiatric,"  vol.  viii.  pt.  1. 


178  MEDICAL    OPHTHALMOSCOPY. 

accompanied  by  distension  of  the  optic  sheath  with  dark- 
coloured  fluid. 

CEREBRO-SPINAL  MENINGITIS. — In  epidemic  cerehro-spinal 
meningitis,  optic  neuritis  may  occur,  but  is  rare.  Schirmer 
found  it  in  one  only  of  twenty-seven  cases  examined.  Von 
Ziemssen1  observed  slight  neuritis  in  one  case,  and  in  another 
a  pale  fundus  with  broad  and  tortuous  veins,  narrow  arteries, 
and  haemorrhages  beside  the  disc;  at  a  later  period  white 
points  appeared  in  the  retina.  Cyclitis  and  retinitis  were 
found  by  Oeller.2  Many  of  the  retinal  veins  contained 
thrombi  and  granular  plugs  ;  no  direct  connection  with  the 
intra-cranial  process  could  be  traced.  A  purulent  irido- 
choroiditis  is  the  most  frequent  change  in  this  disease. 

In  the  sporadic  (possibly  rheumatic)  form  of  cerebro- 
spinal  meningitis,  optic  neuritis  may  occur,  and  may  lead  to 
atrophy.  Thus  Mr.  E.  Pope  of  Tring  recently  showed  me 
a  lad  who,  after  a  severe  wetting,  had  suffered  from  intense 
headache,  delirium,  fever,  and  retraction  of  the  head.  Sight 
failed  ten  days  after  the  onset.  The  symptoms  subsided  at 
the  end  of  six  weeks,  but  he  remained  blind,  and  when  I 
saw  him,  six  months  later,  there  was  slight  perception  of 
light  in  one  eye  only.  The  optic  discs  had  all  the  appear- 
ance of  consecutive  atrophy,  the  centres  were  filled  in  with 
new  tissue,  the  vessels  narrowed,  and  the  adjacent  choroid 
disturbed.  Such  a  case,  however,  is  perhaps  to  be  separated 
from  most  sporadic  cases,  since  in  these  a  conspicuous  exciting 
cause  is  seldom  to  be  traced. 

TRAUMATIC  MENINGITIS  often  causes  ophthalmoscopie 
changes,  of  which  an  instance  is  shown  in  PL  III.  o,  a 
case  in  which  fever,  delirium,  and  convulsions  succeeded  a 
fall  on  the  head.  The  neuritis  subsided  with  the  symptoms. 
These  cases  are  considered  in  the  section — "  Injuries  to  the 
Head."  The  ophthalmoscopie  changes  are  frequent  and 
are  of  the  highest  importance  in  the  many  cases  in  which 
other  symptoms  are  subjective  only,  and  when  the  grave 

1  "  Jahrb.  f.  Ophthalmologie,"  1878,  p.  243. 

2  "Arch.  f.  Augenkrauk.,"  vol.  viii.  1878,  p.  357. 


DISEASES    OF    THE    CRANIAL    BONES. 

nature  of  the  effects  of  the  injury  may  be  doubted  or  even 
denied  by  those  whose  interests  are  opposed. 

DISEASES  OF  THE  CRANIAL  BONES. 

CARIES. — In  caries  of  the  sphenoid  bone,  or  suppuration 
beneath  the  periosteum,  the  inflammation  may  extend  to  the 
optic  nerve,  damaging  it,  and  causing  secondary  atrophy,  orr 
descending  the  nerve,  may  produce  intra-ocular  neuritis.  The 
disc  shown  in  PL  III.  2  is  an  illustration  of  this  effect,  The 
case  was  one  of  caries  of  the  body  of  the  sphenoid  bone  in  a 
girl  aged  sixteen.  There  was  well-marked  neuritis  in  the  left 
eye,  but  for  a  month  afterwards  the  right  eye  was  normal. 
Coincidently  with  an  increase  of  the  symptoms  of  meningitis, 
this  also  became  inflamed,  and  she  died  a  few  days  later.  The 
autopsy  showed  caries  of  the  sphenoid,  chronic  meningitis 
around  the  left  sphenoidal  fissure,  involving  the  sheath  of  the 
left  optic  nerve.  There  was  also  general  acute  purulent 
meningitis,  which  had,  no  doubt,  been  the  cause  of  the  neuritis 
in  the  right  eye.  The  damage  to  the  nerve  was  just  in 
front  of  the  chiasma ;  the  neuritis  coincided  in  onset  with  an 
increase  in  local  symptoms,  which  ended  in  an  attack  of 
meningitis,  from  which  the  patient  died.  When  the  draw- 
ing was  made,  the  neuritis  was  confined  to  the  eye  corre- 
sponding to  the  damaged  nerve ;  soon  after  the  onset  of  the 
meningitis,  a  day  or  two  later,  similar  neuritis  made  its 
appearance  in  the  other  eye.  In  this  case  there  was  no 
change  in  the  sheath  of  the  nerve.  In  a  case  recorded  by 
Horner,  of  caries  of  the  sphenoid,  the  sheath  of  the  optic 
nerve  was  distended  by  purulent  material  as  far  as  the 
eyeball. 

Caries  of  the  bone,  at  a  distance  from  the  optic  nerves,  does 
not  cause  ophthalmoscopic  changes  unless  it  excites  menin- 
gitis or  cerebral  abscess.  To  this,  however,  an  exception 
must  be  made  in  regard  to  disease  of  the  bones  of  the  ear, 
which  there  is  reason  to  believe  may  cause  optic  neuritis 
when  no  abscess  or  meningitis  is  to  be  found.  It  has  been 
suggested  by  Mr.  Arthur  Barker  that  the  papillitis  in  these 


180  MEDICAL   OPHTHALMOSCOPY. 

eases  may  be  the  result  of  a  septic  inflammation  in  the 
middle  ear,  infecting  directly  the  adjacent  carotid  canal, 
and  extending  along  the  lymphatics  of  the  latter  to  the 
sheath  of  the  optic  nerve.  Cases  such  as  he  has  observed 
are  certainly  of  much  clinical  importance,  and  deserve  close 
attention  on  the  part  of  the  pathologist. 

THICKENING  OF  THE  CRANIAL  BONES. — General  thicken- 
ing of  the  cranial  bones  may  cause  optic  neuritis  and  con- 
secutive atrophy.  Neuritis  with  great  swelling  of  the 
papilla,  was  present  in  a  case  of  this  description  in  the  Queen 
Square  Hospital  under  the  care  of  Dr.  Buzzard.  The 
general  thickening  of  the  bones  of  the  skull  appeared  to  be 
of  a  sub-inflammatory  character.  There  was  no  post-mortem 
examination,  as  the  patient  recovered;  but  Michel  has  recorded 
the  case  of  a  boy  who  was  blinded  by  neuritis  and  consecutive 
atrophy  early  in  life,  and  who  died  aged  fifteen.  The  ne- 
cropsy revealed  great  hyperostosis  of  the  bones  of  the  skull, 
by  Which  both  optic  foramina  Were  considerably  narrowed. 
The  optic  nerves  were  atrophied  from  the  chiasma  to  the  eye, 
but  the  orbital  portion  was  greatly  thickened  by  hyperplasia 
of  the  cellular  tissue  in  the  subvaginal  space.  A  similar  case 
has  been  described  by  Manz,  in  which  the  tissue  between  the 
sheath  and  the  nerve  had  a  semi-gelatinous  aspect.  Michel 
•explains  this  change,  by  assuming  that  the  narrowing  of  the 
foramen  leads  to  retention  within  the  sheath  of  lymphatic 
fluids,  which  cause  irritation. 

In  other  cases,  similar  conditions  of  bone,  exostoses,  &c., 
narrowing  the  optic  foramen,  have  caused  only  simple 
atrophy  of  the  optic  nerve. 

DISEASES  OF  THE  ORBIT. 

Inflammatory  Processes  in  the  OrfoY,e.<7.,cellulitis  (as  in  facial 
erysipelas),  inflammation  at  the  back  of  the  orbit,  or  periosteal 
affections  in  which  the  symptoms  and  their  course  point 
clearly  to  the  seat  and  nature  of  the  lesion,  although  the 
pathological  inference  is  still  as  unconfirmed  by  post-mortem 
evidence  as  is  the  case  with  the  analogous  inflammation  of 


DISEASES    OF    THE    ORBIT.  181 

the  facial  nerve,  frequently  damage  the  optic  nerve.  This 
damage  always  involves  inflammation,  which  may  or  may 
not  be  seen  in  the  papilla.  The  difference  depends  partly 
on  its  tendency  to  spread  down  the  nerve,  coupled  with 
its  proximity  to  the  eye  or  distance  from  it,  and  partly, 
perhaps,  on  the  compression  of  the  vein.  But  whether  there 
is  neuritis  or  not,  atrophy  is  subsequently  visible,  propor- 
tioned, in  degree,  to  the  impairment  of  sight.  This  may 
or  may  not  have  the  aspect  of  "  consecutive  atrophy." 
There  may  be  neuritis  and  its  effects,  but  the  affection  of 
sight  may  be  due  chiefly,  not  to  the  visible  inflammation, 
but  to  the  changes  behind  the  eye,  at  the  spot  primarily 
diseased.  Hence  care  must  be  taken  (as  pointed  out  in  the 
account  of  secondary  atrophy)  not  to  regard  the  papillitis  as 
the  chief  cause  of  a  failure  of  sight  that  may  occur  without 
any  intra-ocular  inflammation.  It  is  of  practical  importance 
to  remember  that  no  forecast  can  be  drawn  from  the  visible 
inflammation — that  the  absence  of  this  affords  no  ground 
for  a  good  prognosis.  In  the  one  case,  the  nerve  is  simply 
compressed  by  the  inflammatory  products,  or,  if  inflamed, 
the  inflammation  is  localized.  Sight  is  lost  sometimes  very 
rapidly,  and  simple  secondary  atrophy  of  the  lower  portion 
of  the  nerve  results,  occasionally  with  ultimate  narrowing 
of  the  vessels  (Allbutt  and  Teale).  In  the  other  case,  the 
inflammation  is  communicated  to  the  nerve,  and  descends 
along  it  to  the  eye,  or  inflammatory  processes  in  the  sheath 
lead  to  a  secondary  papillitis.  In  many  cases  the  eyeball 
becomes  prominent,  usually  only  in  slight  degree,  and  the 
absence  of  such  prominence  is  of  no  negative  significance. 
The  exophthalmos  depends  on  the  amount  of  effusion  and  its 
character.  The  nerves  may  be  gravely  damaged  when  the 
general  orbital  inflammation  is  slight. 

PL  II.  3  affords  an  example  of  the  occurrence  of  simple 
atrophy  of  the  nerve  due  to  this  cause.  It  is  an  illustration 
of  a  well-marked  type,1  in  which  loss  of  sight  of  one  eye 
comes  on  simultaneously  with  paralysis  of  all  the  ocular 

1  For  example,  those  recorded  by  v.  Graefe,  "Arch.  f.  Ophth.,"  vol.  i. 
pt.  1,  p.  424,  and  Baumeister,  ibid.  vol.  xix.  pt.  2,  p.  264. 


182  MEDICAL    OPHTHALMOSCOPY. 

muscles,  sometimes  with  tenderness  on  pressing  the  eyeball 
back  into  the  orbit.  The  symptoms  have  been  ascribed  to 
haemorrhage  (v.  Grraefe)  or  inflammatory  mischief  (Bau- 
meister)  at  the  back  of  the  orbit.  In  the  case  illustrated, 
the  cause  was  almost  certainly  "  rheumatic "  inflammatory 
mischief,  for  the  symptoms  came  on  suddenly,  with  much 
pain,  after  exposure  to  cold,  in  an  intensely  rheumatic 
woman,  who  had  previously  had  an  attack  of  "  rheumatic  " 
paralysis  of  the  facial  nerve.  The  paralysis  of  the  ocular 
muscles  passed  away,  but  that  of  the  optic  nerve  persisted, 
and  the  disc  slowly  passed  into  atrophy  without  the  least 
sign  of  neuritis.  In  such  a  case  it  is  probable  that  the  nerve 
suffered  chiefly  from  pressure.  A  case  of  rapid  but  not 
permanent  failure  of  sight,  accompanied  with  shooting  pains 
passing  to  the  back  of  the  head,  in  a  woman  who  had  had 
facial  paralysis,  has  been  recorded  by  Nettleship.1  There 
was  slight  puffiness  of  the  eyelids,  but  no  tenderness  on 
pressing  the  eyeball  back,  and  the  ophthalmoscopic  appear- 
ances were  normal. 

In  another  case,  probably  of  syphilitic  mischief  at  the 
back  of  the  orbit,  with  intense  pain  in  the  eye,  orbit, 
and  head,  the  inflammation  descended  to  the  eye,  and 
produced  secondary  .papillitis,  ending  in  atrophy.  In  this 
case  sight  was  lost,  and  the  vision  of  the  other  eye  also 
became  impaired.  Hence  it  is  probable  that  the  inflamma- 
tion extended  from  one  optic  nerve  to  the  other,  probably 
by  the  chiasma — a  danger  that  makes  energetic,  prompt 
treatment  imperative. 

A  very  similar  state  of  secondary  atrophy  of  the  nerve 
may  result  from  a  blow  on  the  head,2  or  on  the  eye.  Rapid 
exophthalmos  and  the  appearance  of  the  lids  may  show  that 
haemorrhage  has  occurred  into  the  orbit.  These  conditions 
are  considered  in  the  section  on  "  Injuries  to  the  Head." 

In  rare  instances,  haemorrhage  has  occurred  apart  from 
injury,  in  sufficient  quantity  to  cause  prominence  of  the 
eyeball  and  distension  of  the  eyelids  with  blood.  Of  two 

1  "  Laucet,"  1881,  i.  p.  760. 

2  Snell:  "  Ophth.  Rev.,"  i.  402. 


INJURIES    TO   THE    HEAD.  183 

cases  recorded  by  Ayres,1  the  exciting  cause  in  one  was  a 
violent  effort,  in  the  other  a  strain  during  vomiting.  The 
degree  of  impairment  of  sight  appears  to  depend  upon  the 
amount  of  blood  effused,  and  the  consequent  stretching  of 
the  optic  nerve. 

Tumours  in  the  Orbit. — A  tumour  at  the  back  of  the  orbit 
or  of  the  optic  nerve,  may  cause  neuritis  such  as  results 
from  intra-cranial  tumour,  but  this  is  at  first  limited  to  the 
eye  in  front  of  the  growth ;  the  other  optic  papilla  either 
escapes  or  presents  only  a  slighter  and  later  inflammation, 
which  has  been  communicated  to  the  nerve  through  the 
chiasma.  There  is  also  distinct  and  increasing  prominence 
of  the  eyeball. 

INJURIES  TO  THE  HEAD. 

Injuries  to  the  head,  blows,  falls,  &c.,  frequently  cause 
ocular  symptoms  and  often  very  marked  ophthalmoscopic 
signs.  The  forms  of  ocular  affection  are  of  several  varieties. 

1.  Impairment  or  loss  of  sight,  without  ophthalmoscopic 
changes,  or  with  very  slight  alterations — simple  congestion 
of  the  disc,  easily  overlooked.     Such  impairment  may  result 
from  blows  on  the  anterior  portion  of  the  head.     In  some 
cases  the  mischief  is  probably  direct  concussion  of  the  retina, 
for  in  slight  cases  an  alteration  of  vision  has  been  noted  such 
as  must  be  ascribed  to  disturbance  of  the  retinal  elements. 
For  instance,  in  a  case  recorded  by  Gfosetti,  after  a  blow  on 
one  angle  of  the  orbit,  near  objects  appeared  unduly  large, 
-and  there  was  some  colour-blindness,  but  no  ophthalmoscopic 
change. 

2.  Optic  neuritis  has  followed  injuries  to  the  head  in  many 
cases,  at  an  interval  of  a  few  days  or  weeks.     It  is  apparently 
due  to  secondary  results  of  injury,  especially  to  meningitis 
(PI.  III.  5),  less  commonly  to  traumatic  inflammatory  soften- 
ing of  the  brain  or  hernia  cerebri.     In  a  case  under  my  own 
observation,  there  was  a  compound  depressed  fracture  of  the 
left  parietal  bone.     This  was  elevated  five  weeks  after  the 

1  "Archives  of  Ophthalmology,"  vol.  x.  pt.  1,  March,  1881,  p.  42. 


184  MEDICAL   OPHTHALMOSCOPY. 

injury,  but  a  few  days  later  hernia  cerebri  occurred.  The 
optic  discs  were  then  normal,  but  five  days  later  there  was 
acute  optic  neuritis,  which  persisted  until  death. 

The  neuritis  may  be  slight  or  considerable,  and  may 
entail  loss  of  sight  and  consecutive  atrophy.  When 
occurring  long  after  an  injury  it  may  be  due  to  abscess  of 
the  brain,  as  was  possibly  the  case  in  a  patient  who  pre- 
sented double  papillitis  a  year  after  a  violent  blow  from 
an  exploded  shell,  over  one  eyebrow,  which  ultimately 
caused  necrosis  of  bone.1 

3.  Simple    atrophy    of    the    optic    nerves,  unilateral  or 
bilateral,  may  result  from  injuries  which  damage  the  optic 
nerves,  directly  or  by  pressure  from  secondary  inflammation. 
An  example  of  this  condition  was  met  with  in  a  patient  in 
whom  a  fall  on   the  right  side  of  the  head  and  shoulder, 
injuring  the  circumflex  nerve,  was  followed  by  slow  grey 
atropjiy  of  the  right  optic  disc.     In  such  cases  sight  often 
fails  some  time  before  the  ophthalmoscopic  signs  of  atrophy 
are  apparent.     See  below,  "  Fracture  of  the  Skull." 

4.  In  some  cases  an  injury  to  the  head  may  be  followed 
by  gradual  failure  of  sight,  with  very  slight  and  stationary 
papillitis.     In   such   cases  it   is    probable    that    a    chronic 
interstitial  neuritis  has  been  set  up  in  the  nerve  trunk. 

Concussion  of  the  Brain  is  attended  by  no  ophthalmoscopic 
change.  Simple  concussion  of  the  nerve  and  retina  may 
probably,  as  just  stated,  cause  loss  of  sight  and  slow  atrophy. 

Contusion  and  Laceration  of  the  Brain  may  entail  optic 
neuritis,  commonly  slight  in  degree,  although  sometimes 
marked  with  increased  vascularity  and  redness  and  opacity 
of  the  adjacent  retina.  It  is  apparently  due,  in  some  cases, 
to  a  secondary  meningitis,  but  may  occur  directly  from  the 
brain  lesion.  It  may  constitute  a  valuable  indication  of 
the  occurrence  of  greater  mischief  than  a  mere  concussion. 
For  instance,  in  a  case  recorded  by  Grazet,2  the  symptoms  of 
concussion  were  followed  by  neuritis  and  consecutive  atrophy, 
and  ten  weeks  after  the  injury  the  necropsy  showed  two  foci 

1  Recorded  by  Boncour  :  "  Journ.  d'Ophth.,"  July,  1872. 

2  "  I/Union  Med.,"  1865,  ii.  3,  No.  63. 


INJURIES   TO   THE    HEAD.  185- 

of  red  softening  in  the  right  anterior  lobe  and  one  in  the 
corpus  callosum.  Panas  has  found  in  such  cases  distension  of 
the  sheath  of  the  nerve,  and  it  is  assumed,  on  the  Schmidt  - 
Manz  theory,  that  thus  the  neuritis  is  produced,  but  this  is 
at  present  unproved. 

Fracture  of  the  Skull1  not  uncommonly  causes  loss  of  sight 
in  consequence  of  laceration  of  the  optic  nerve.  According 
to  the  statistics  of  Holder,  quoted  by  Berlin,  the  orbital  vault 
is  involved  in  90  per  cent,  of  fractures  of  the  base  of  the 
skull  (80  out  of  88  cases),  and  the  optic  canal  is  implicated  in 
54  (or  60  per  cent.).  In  42  of  these  there  was  haemorrhage 
into  the  sheath  of  the  optic  nerve.  The  most  frequent  causes 
are  blows  and  falls  on  the  frontal  bone  (especially  the  orbital 
portion),  less  frequently  on  the  temporal  or  occipital  bone. 
The  effect  of  the  resulting  laceration  of  the  nerve  is  usually 
immediate  and  permanent  loss  of  sight.  It  is  generally 
unilateral  and  on  the  side  of  the  injury,  very  rarely  on  the 
opposite  side,  as  in  a  case  recorded  by  Leber  and  Deutsch- 
mann,  in  which  the  eye  blinded  was  on  the  side  opposite 
to  that  on  which  blood  escaped  from  the  ear.  Both  eyes  are 
only  affected  when  both  optic  canals  are  fractured.  Some- 
times the  haemorrhage  into  the  orbit  is  evidenced  by  promi- 
nence of  the  eyeball  and  effusion  of  blood  into  the  eyelids.  The 
optic  nerve  may  be  torn,  compressed,  stretched,  or  the  seat 
of  haemorrhage.  Absolute  loss  of  sight  from  direct  injury 
to  the  nerves  is  usually  permanent.  When  the  lesion,  as  is- 
commonly  the  case,  is  behind  the  place  of  entrance  of  the 
central  vessels,  there  is  at  first  no  ophthalmoscopic  change 
or  only  transient  retinal  hyperaemia,  but  atrophy'  gradually 
sets  in.  The  pallor  has  been  observed  to  commence  three 
weeks  after  the  injury.  The  ultimate  appearance  of  the 
disc  is  usually  that  of  simple  atrophy,  the  edges  sharp,  and 
the  vessels  of  normal  size.  Sometimes  narrowing  of  the 

1  The  statements  in  the  text  are,  in  part,  derived  from  important  papers 
by  Berlin  ("  Heidelberg  Ophth.  Gesellsch.,"  1879,  and  "Annaies  d'Oculis- 
tique,"vol.  Ixxxiii.,  1880,  p.  69),  and  by  Leber  and  Deutschmann,  "Arch.  f. 
Ophth.,"  vol.  xxvii.  pt.  274.  See  also  Graefe  and  Saemisch's  "Handbuch," 
vol.  v.  p.  219. 


186  MEDICAL    OPHTHALMOSCOPY. 

vessels  has  been  observed,  and  has  been  ascribed  to  the 
extension  of  inflammation  to  the  tissue  around  the  vessels, 
or  to  their  direct  compression  by  the  injury,  or  by  effusion 
of  blood.  Ophthalmoscopic  signs  of  inflammation  are  not 
common,  except  as  a  result  of  subsequent  meningitis,  but, 
in  one  of  my  cases,  oedema  of  the  disc  with  retinal  haemor- 
rhages accompanied  effusion  of  blood  into  the  optic  sheath. 
If  the  injury  to  the  nerve  is  in  front  of  the  place  of  entrance 
of  the  central  artery,  the  ophthalmoscopic  appearances  are 
similar  to  those  of  embolism.  When  the  injury  to  the  nerve 
is  partial,  the  loss  of  sight  may  be  incomplete,  and  in  such 
cases  central  scotomata  and  peripheral  limitation  of  the  field 
have  been  observed.  When  sight  is  impaired  by  effusion 
of  blood  into  the  sheath,  the  prognosis  is  said  to  be  better 
than  when  the  nerve  is  injured.  Occasionally  signs  of  direct 
injury  to  the  eye  have  been  observed  in  these  cases,  rupture 
of  the  choroid  or  vitreal  opacities. 

Compression  of  the  Brain  may,  it  is  said,  be  attended  by 
changes  in  the  fundus  oculi — distension  of  the  retinal  veins, 
congestion  and  oedema  of  the  papilla.  Such  appearances  are, 
however,  certainly  rare. 

Traumatic  Meningitis  entails,  very  commonly,  ophthal- 
moscopic changes  similar,  for  the  most  part,  to  those  which 
are  found  in  tubercular  meningitis.  Meningitis  often  results 
from  fracture  of  the  base  of  the  skull,  and  may,  like  tuber- 
cular meningitis,  be  attended  with  neuritis.  An  instance 
of  traumatic  mischief  with  neuritis  is  afforded  by  the  case 
figured  in  PI.  III.  5.  The  neuritis  came  on  with  mental 
disturbance  and  convulsions,  following,  at  an  interval  of  a 
week,  a  fall  on  the  head.  The  change  was  slight  in  degree, 
although  very  distinct,  and  passed  away  soon  after  the 
cerebral  symptoms  subsided,  leaving  no  trace.  When  the 
neuritis  is  more  intense,  blindness  may  result.  Hock l  has 
described  the  case  of  a  child  who  had  symptoms  of  menin- 
gitis five  months  after  a  fall  on  the  head.  Optic  neuritis 
("  descending  ")  was  found  with  the  ophthalmoscope,  sight 

1  "  Oest.  Jahrb.  fur  Padiatrik,"  vol.  v.  1874,  p.  1.  "  Nagel's  Jahrb.  f. 
Ophth.,"  vol.  v.  p.  427. 


DISEASES   OF   THE   NOSE.  187 

being  little  impaired.  Four  years  later,  however,  the  child 
was  healthy  hut  blind,  with  atrophy  of  both  optic  nerves.  In 
other  cases  of  the  kind  actual  meningitis  has  been  found. 
The  neuritis  may  be  associated  with  the  signs  of  mischief  at 
the  base  of  the  brain,  paralysis  of  ocular  muscles,  &c.  The 
chronic  inflammatory  consequences  of  an  injury  (chronic 
meningitis,  inflammatory  "  growths,"  &c.)  may  persist  and 
progress  for  a  long  time,  even  for  years,  as  in  a  case  .in 
which  meningeal  growths,  apparently  the  result  of  chronic 
inflammation,  were  found  beneath  two  old  fractures  of  the 
skull,  the  result  of  injuries  received  several  years  previously. 
At  the  base  the  results  of  chronic  meningitis  had  damaged 
the  arteries  and  caused  fatal  softening,  but  no  recent 
•change. 

Hernia  Cerebri,  resulting  from  fracture  of  the  skull,  with 
loss  of  bone,  may  be  accompanied  with  neuritis,  as  in  the 
case  referred  to  on  page  183. 

Necrosis  of  the  Cranial  Bones. — The  damage  to  bone  by 
injury  may  cause  necrosis  and  meningitis  or  abscess  of  the 
brain,  both  of  which  may  entail  inflammation  of  the  optic 
nerve.  As  Hughlings-Jackson  has  pointed  out,  the  relation 
of  the  symptoms  to  the  injury  may  be  obscure  and  unsus- 
pected by  the  patient  or  friends,  so  that  careful  attention 
should  be  paid  to  any  sign  of  injury,  such  as  puffy  swelling, 
<&c.,  and  the  occurrence  of  a  blow  or  fall  should  be  carefully 
inquired  for  in  all  cases  of  local  brain  disease. 


DISEASES  OF  THE  NOSE. 

Some  curious  cases  have  been  recorded1  in  which  optic 
neuritis  coincided  with  persistent  discharge  of  watery  fluid 
from  one  nostril.  In  most  cases  there  were  chronic  cerebral 
symptoms,  and  in  some  there  were  polypoid  growths  in  the 
nose. 

The  fluid  is  not  cerebro-spinal  fluid,  nor  is  it  ordinary  nasal 

]  See  Nettleship :  "Oph.  Rev.,"  1883,  and  Emrys  Joues  :  "Oph.  Rev.," 
vii.  97. 


188  MEDICAL   OPHTHALMOSCOPY. 

secretion.  The  most  probable  explanation  is  that  there  is 
increased  intra-cranial  pressure  and  hydrocephalus,  and  that 
the  escape  of  fluid  relieves  the  pressure  indirectly,  and  that 
it  is  conditioned  by  some  abnormal  state  of  the  mucous 
membrane  of  the  nose.  In  a  case  recorded  by  Baxter,1 
however,  there  was  no  disease,  but  the  bones  of  the  skull 
were  abnormally  thick.  But  in  this  case  the  cerebral  symp- 
toms were  rather  those  of  functional  than  of  organic- 
disease.  To  increase  the  mystery,  some  of  the  cases  pre- 
sented slight  symptoms  of  exophthalmic  goitre. 


INSOLATION  AND  HEATSTROKE. 

The  occurrence  of  congestion  of  the  optic  discs  in  cases  of 
severe  sunstroke,  described  by  Macnamara,  has  been  before 
alluded  to  (p.  138).  In  America,  according  to  Hotz,2  it  is 
not  uncommon  to  meet  with  cases  of  atrophy  of  the  optic 
nerves,  which  are  ascribed  by  the  patients  to  sunstroke. 
Commonly  the  arteries  are  narrowed,  as  if  from  preceding 
inflammation,  and  in  some  recent  cases  he  met  with  actual 
neuritis.  In  three  the  exposure  had  been  to  the  sun,  in  three 
to  an  intense  heat.  Severe  headache  was  a  prominent  early 
symptom,  and  it  is  probable  that  the  neuritis  was  secondary 
to  acute  cerebral  congestion  or  meningitis. 

Hotz  has  also  seen  exudative  choroiditis  apparently  from 
the  same  cause,  in  degree  sufficient  to  cause  detachment  of 
the  retina.  He  regards  it  as  due  to  the  extension  of  inflam- 
mation along  the  sheath  of  the  optic  nerve,  but  the  absence 
of  choroiditis  in  other  cases  of  such  extension  renders  the 
explanation  difficult  to  accept. 

1  "Brain,"  v.  325. 

2  "American  Journal  of  Medical  Science,"  July,  1879. 


INFLAMMATION.  189 

DISEASES   OF  THE  SPINAL   CORD. 
INFLAMMATION. 

Spinal  meningitis  may  be  accompanied  by  ophthal- 
moscopic  changes  when  the  cerebral  membranes  are  also 
affected  (see  "  Cerebro-Spinal  Meningitis,"  p.  178).  But 
we  must  be  prepared  to  meet  with  neuritis  as  a  coincidence 
of  any  local  inflammation  that  is  produced  by  a  blood-state, 
so  many  and  various  are  the  states  of  the  blood  in  which 
the  papilla  becomes  inflamed. 

Myelitis  is  an  illustration  of  the  same  truth.  It  is  also 
usually  unattended  by  any  changes  in  the  eye,  but  to  this 
rule  several  remarkable  exceptions  have  been  recorded. 
They  show,  conclusively,  that  the  papilla  is  susceptible  to 
some  states  of  the  blood  that  influence  the  spinal  cord. 
Slight  optic  neuritis,  veiling  the  edges  of  the  discs,  was 
seen  by  Clifford  Allbutt  in  a  case  of  chronic  myelitis  in 
the  upper  dorsal  region.  Partial  grey  atrophy  supervened. 
The  same  observer  has  also  met  with  partial  atrophy  after 
dorsal  myelitis.  Seguin1  has  twice  seen  optic  neuritis 
coincident  with  subacute  transverse  myelitis.  The  affection 
of  the  optic  nerves  ran  a  favourable  course  and  left  no 
impairment  of  sight.  Noyes2  has  recorded  the  case  of  a 
young  man  in  whom,  without  cause,  impairment  of  sight 
in  the  right  eye  was  simultaneous  with  some  spinal  symp- 
toms, and  a  fortnight  later  slight  optic  neuritis  was  found. 
The  spinal  symptoms  (initial  retention  of  urine,  tingling, 
and  some  anaesthesia  in  the  legs)  did  not  increase,  but  the 
fields  of  vision  became  changed  in  a  peculiar  and  irregular 
manner,  suggesting  an  affection  of  the  chiasma  or  optic 
tracts. 

In  a  man,  aged  fifty-two,  whose  case  has  been  recorded  by 

1  "  Journal  of  Nervous  and  Mental  Disease,"  April,  1880. 
~  "Archives  of  Ophthalmology,"  vol.  ix.  1880,  pt.  ii.  p.  199. 


190  MEDICAL    OPHTHALMOSCOPY. 

Steffen l  and  by  Erb,2  loss  of  sight,  commencing  by  a  central 
scotoma,  and  accompanied  by  slight  neuritis,  occurred  first  in 
the  left  eye,  and,  three  weeks  later,  in  the  right.  Sight 
slowly  returned,  but  three  months  later  there  was  renewed 
failure  in  both  eyes  with  temporal  hemianopia,  without 
marked  ophthalmoscopic  changes.  Two  months  later  the 
symptoms  of  a  transverse  dorsal  myelitis  came  on. 

Very  significant  also  are  two  cases  of  coincident  neuritis 
and  myelitis  observed  by  Dr.  Dreschfeld,  of  Manchester. 
One  was  a  man  aged  forty-one,  who,  simultaneously  with 
an  attack  of  double  optic  neuritis  going  on  to  complete 
atrophy,  and  slight  mental  disturbance,  presented  the 
symptoms  of  acute  myelitis,  from  which  he  died  at  the  end 
of  a  month.  The  necropsy  revealed  disseminated  acute 
inflammation  of  the  spinal  cord  in  the  dorsal  and  lumbar 
regions.  The  brain  appeared  healthy.  The  other  case  was 
that  of  a  woman,  aged  thirty-eight,  who  died  from  res- 
piratory paralysis  six  weeks  after  the  onset  of  symptoms  of 
acute  myelitis.  Soon  after  the  paralysis  came  on,  double 
optic  neuritis  was  found  to  exist.  After  death  the  brain 
presented  merely  signs  of  congestion,  but  the  upper  part  of 
the  spinal  cord  was  softened. 

It  is  probable  that,  in  these  cases,  the  optic  neuritis  and 
myelitis  were  both  the  result  of  a  common  cause.  The 
coincidence  of  acute  inflammation  of  the  optic  nerve  and 
spinal  cord  is  of  considerable  interest  in  connection  with 
their  frequent  affection  in  chronic  disease.  It  is  probable, 
however,  that  in  some  cases  (Noyes,  Steffen)  the  cause  of  the 
neuritis  was  situated  at  or  near  the  chiasma. 

SCLEROSIS  or  THE  CORD. 

POSTERIOR   SCLEROSIS  I      LOCOMOTOR   ATAXY. 

Atrophy  of  the  optic  nerves  is,  as  is  well  known,  frequent 
in  locomotor  ataxy.  In  what  proportion  of  the  cases  it 

1  "  Sitzungsbericht  der  Heidelberg  Ophth.  Gesellschaft,"  1879. 

2  "  Archiv  fur  Psychiatric,"  vol.  x.  p.  146. 


SCLEROSIS    OF  THE    CORD.  191 

occurs  is  difficult  to  say.  Ophthalmic  surgeons  have  been 
impressed  with  its  frequency.  Charcot  believes  that  almost 
all  cases  of  so-called  simple  atrophy  ultimately  present  spinal 
symptoms.  Careful  statistics  show  that  the  proportion  of 
the  cases  of  simple  atrophy  in  which  spinal  symptoms  of  any 
kind  can  be  recognized  is  about  one-half  (see  p.  112). 

But  we  must  not  infer  from  this  the  converse  proposi- 
tion that  most  cases  of  ataxy  present  optic  nerve  atrophy. 
It  is  probably  near  the  truth  to  say  that  about  one  ataxic 
in  six  suffers  from  optic  atrophy.     Of  seventy  consecutive 
cases  of  ataxy  which  have  come  under  my  observation,  only 
nine  presented  atrophy.     It  existed  in  nine  out  of  fifty-two 
cases  recorded  by  Voigt,1  and  in  seven  out  of  fifty-six  cases 
analyzed  by  Erb.2     Thus  of  178  cases  of  ataxy,  optic  nerve 
atrophy  existed  in  twenty-five,  or  14  per  cent.    When  it  does 
occur,  it  is  more  frequently  an  early  than  a  late  symptom, 
occurring  before  rather  than  after  the  difficulty  in  walking 
has  become  considerable.     In  the  nine  cases  above  referred  to, 
the  onset  of  the  atrophy  preceded  any  distinct  disturbance  of 
locomotion  in  eight.     In  only  one  case  did  it  develop  after 
the  inco-ordination  was  considerable,  and  in  this  the  spinal 
symptoms  came  on  very  rapidly.     When  sight  is  lost,  any 
inco-ordination  which  exists  is  greatly  increased — the  con- 
dition which  the  physician  employs  as  a  test  to  exaggerate 
the  difficulty,  the  withdrawal  of  the  guiding  visual  sensation, 
being  permanent.     The  ataxic  symptoms  are  often  so  slight 
that,  even  as  increased  by  the  blindness,  a  careful  investi- 
gation is  necessary  to  discover  them.     Blind  people  often 
walk  in  a  more  or  less  hesitating  and  uncertain  manner,  and 
the  uncertainty  of   slight   ataxy  is  easily  attributed  to  the 
blindness.    Inquiry,   however,    elicits    other    symptoms,   as 
pains  in  the  limbs,  especially  "  lightning  pains,"  and  loss  of 
sexual  power,  and  careful  observation  of  the  gait  shows  an 
unsteadiness  in  turning,  and  in  standing  with  the  feet  bare, 
and  toes  and  heels  close  together.    It  is,  however,  well  known 
that  the  atrophy  may  occur  before  any  obvious  symptoms 

1  "  Berl.  Kl.  Wochenschrift, "  1881,  lSTo.  39. 

2  "  Deut.  Arch.  f.  Kl.  Med.,"  1879. 


192  MEDICAL    OPHTHALMOSCOPY. 

referable  to  the  cord.  One  extreme  instance  of  this  early 
atrophy  has  come  under  my  own  observation,  in  which  the 
atrophy  of  the  discs  was  complete,  and  vision  lost  for  twenty 
years  before  the  first  symptoms  of  ataxy  showed  themselves. 
I  have  seen  another  case  in  which  the  loss  of  sight  preceded 
for  sixteen  years  distinct  spinal  symptoms.  But  in  many 
such  cases  the  loss  of  the  "  knee-jerk," l  an  early  symptom  in 
ataxy  to  which  Westphal  first  called  attention,  precedes  other 
symptoms,  and  if  looked  for  will  often  be  found  to  co-exist 
with  optic  nerve  atrophy  when  other  symptoms  of  ataxy 
are  absent.  A  very  marked  example  of  this  relation,  in 
which  the  atrophy  existed  for  fifteen  years,  associated  only 
with  lightning  pains  and  loss  of  the  knee-jerk,  has  been 
related  by  Buzzard.2  Another  early  symptom  is  the  loss  of 
the  reflex  action  of  the  pupil  to  light,  although  the  contraction 
occurs  on  an  effort  at  accommodation  (Argyll  Robertson). 
The  pupils  are  often  small  ("  spinal  my osis").  It  is  to  be 
remarked,  however,  that  this  may  co-exist  with  optic  nerve 
atrophy  without  any  spinal  symptom,  as  in  the  case  men- 
tioned on  p.  266. 

When  the  atrophy  is  advanced,  the  optic  discs  are  usually 
grey,  even  to  indirect  examination,  and  to  direct  examination 
very  grey  and  mottled,  the  meshes  of  the  lamina  cribrosa 
may  or  may  not  be  visible,  the  edges  sharp  and  clear, 
the  sclerotic  ring  distinct.  Sometimes  there  is  a  peculiar 
gelatinous  opacity  of  the  substance  of  the  disc.  To  ordi- 
nary daylight  the  tint  is  a  greenish  grey;  to  gaslight  a 
bluish  or  iron  grey.  Its  characters  are  shown  in  PI.  II.  6. 
Less  commonly,  the  discs  appear  white  to  the  indirect 
method  of  examination,  but  a  grey  mottling  can  always  be 
seen  with  the  direct  method.  The  vessels  are  usually  of  the 
normal  size.  The  grey  disc  and  normal  vessels  have  been 
supposed  to  be  peculiar  to  this  form  of  atrophy,  but  this  is 

1  It  must  not  be  hastily  inferred,  however,  from  the  occurrence  of  the  jerk, 
that  the  atrophy  is  unconnected  with  disease  of  the  cord,  because  lateral 
sclerosis,  in  which  there  is  an  excess  of  the  knee-jerk,  may,  in  rare  cases,  be 
Accompanied  by  optic  nerve  atrophy. 

2  "  Brain,"  1878,  No.  2,  p.  168. 


SCLEROSIS   OF   THE    CORD.  193 

incorrect.  The  disc  in  atrophy  from  post-orbital  pressure  on 
the  nerve,  such  as  that  shown  in  PL  II.  3,  may  present 
exactly  the  characters  of  the  atrophy  of  ataxy. 

A  stage  of  hyperaemia,  "  chronic  optic  neuritis,"  has  been 
described  by  Dr.  Clifford  Allbutt  as  sometimes  preceding  the 
atrophy,  but  the  occurrence  of  this  condition  has  not  been 
confirmed  by  other  observers.  I  have  frequently  looked  for 
it,  but  without  success. 

The  anatomical  characters  of  the  atrophy  have  been  already 
described  (p.  116).  The  trunk  of  the  optic  nerve  is  commonly 
nearly  normal  in  size,  but  is  grey  and  semi-translucent.  The 
grey  degeneration  may  stop  at  the  chiasma,  but  often,  as 
Tiirck  pointed  out,  involves  also  the  optic  tracts,  and  can  be 
traced  to  the  external  corpora  geniculata.  The  microscopical 
investigations  (of  Leber  especially)  have  shown  that  the 
change  in  the  nerve  consists  of  an  increase  in  the  interstitial 
tissue,  and  sometimes  the  formation  of  translucent  colloidal 
tissue  around  the  vessels,  as  in  Fig.  51,  p.  117,  together 
with  a  wasting  of  the  nerve  fibres.  The  histological  resem- 
blance to  the  change  in  the  spinal  cord  is  not  so  close  as 
has  been  asserted.  Charcot  and  Abadie  have  suggested  that 
the  change  commences  in  the  nerve  fibres,  and  is  essentially 
parenchymatous,  but  the  balance  of  evidence  is  not  by  any 
means  conclusively  in  favour  of  this  view. 

The  affection  is  usually  bilateral,  although  often  more 
advanced  in  one  eye  than  in  the  other.  In  rare  cases,  one 
eye  may  be  much  aifected,  and  the  other  very  little. 

Symptoms. — The  affection  of  sight  is  usually  characterized 
by  a  progressive  peripheral  defect  in  the  field  of  vision, 
especially  extensive  on  the  outer  side  (Forster) .  It  progresses 
until  only  a  small  portion  is  left,  situated  to  the  inner  side 
of  the  blind  spot,  and  enclosing  the  fixing  point.  Central 
vision  may  be  little  impaired  even  after  the  peripheral  defect 
has  become  very  great.  When  the  acuity  of  vision  is  thus 
preserved  patients  may,  for  a  long  time,  be  unaware  of  the 
affection  of  sight,  until  indeed  the  field  is  greatly  reduced. 
Sometimes  a  sector-like  defect  occurs,  an  example  of  which 
is  figured  at  p.  125.  Rarely  one  half  of  a  field  may 

•  o 


194  MEDICAL   OPHTHALMOSCOPY. 

be  lost  (Fig.  56,  p.  124).  This  has  hitherto  only  been 
observed  when  the  sight  of  the  other  eye  was  entirely 
lost. 

Colour-blindness  is  frequent,  and  is  almost  always  an 
early  symptom.  The  first  change  is  commonly  a  loss  of 
perception  of  green,  then  of  red  (see  p.  120).  Occasionally, 
as  I  have  seen,  the  defect  in  the  field  may  be  more  per- 
ceptible in  a  bright  than  in  a  dim  light,  and  the  latter 
be  preferred  by  the  patient.  The  degree  of  impairment  of 
sight,  both  in  regard  to  acuity  and  to  colour-vision,  may 
vary  from  day  to  day,  just  as  does  the  degree  of  impair- 
ment of  sensibility  in  the  legs. 

The  manner  in  which  the  atrophy  often  precedes  the 
symptoms  of  spinal  mischief  points  to  the  anatomical  in- 
dependence of  the  two  affections,  whatever  may  be  their 
relations.  Pathology  verifies  this  conclusion,  for  in  cases 
in  which  both  posterior  columns  and  optic  nerves  are  affected, 
no  anatomical  continuity  of  degeneration  can  be  traced. 
The  degeneration  extends  as  far  as  the  chiasma,  but  the 
tracts  are  little  affected.  Thus  there  is  an  apparent  want  of 
correspondence  between  the  optic  and  spinal  phenomena. 
Both  are,  it  is  true,  parts  of  the  sensory  nervous  system,  but 
in  the  nerve  the  seat  of  the  morbid  process  is  peripheral,  in 
the  cord  it  is  central.  It  is,  however,  asserted  by  Pierret1 
that  this  opposition  is  apparent  only.  Although  the  de- 
generation of  the  optic  nerves  can  be  traced  only  as  far  as 
the  chiasma,  he  has  frequently  found,  in  the  corpora  quad- 
rigemina,  anterior  and  posterior,  a  process  of  sclerosis,  which 
thus,  at  the  root  of  the  optic  nerve,  represents  the  sclerosis 
at  the  roots  of  the  spinal  nerves.  Further,  the  latter  may, 
he  says,  be  found  changed  in  the  same  manner  as  the  optic 
nerve.  On  examination  of  the  terminal  expansions  of  the 
nerves  of  the  anaesthetic  and  painful  regions  he  has  found  in 
two  cases  the  evidence  of  lesions  of  these  nerves  perfectly 
comparable  to  that  which  constitutes  optic  nerve  atrophy. 
The  farther  from  the  peripheral  termination  the  nerves  are 

1  Quoted  by  Robin,  op.  cit.  The  statements  in  the  text  are  partly  derived 
from  a  communication  M.  Pierret  has  kindly  made  to  me  on  the  subject. 


INSULAR  (DISSEMINATED)  SCLEROSIS.  195 

examined,  the  slighter  do  the  changes  become,  and  soon  they 
disappear,  and  the  nerves  are  healthy,  until  the  posterior 
columns  are  reached.  Thus,  according  to  this  view,  in 
locomotor  ataxy  we  have  a  combined  peripheral  and  central 
change  in  the  sensory  nervous  system ;  and  it  has  been 
merely  an  accident  of  pathological  progress  that  attention 
has  been  primarily  fixed  on  the  central  alteration  in  the  cord 
and  the  peripheral  process  in  the  optic  nerve.  But,  as  has 
been  pointed  out  by  Ghinn,  the  optic  nerve  is  to  be  regarded 
rather  as  part  of  the  central  nervous  system  than  as  an 
ordinary  peripheral  nerve,  and  the  importance  of  this 
relationship  must  be  borne  in  mind  (see  p.  112). 

The  course  of  the  optic  nerve  atrophy  is  very  like  that  of 
the  cord  degeneration.  Recovery  of  sight,  if  ever  observed, 
is  a  still  rarer  event  than  recovery  of  co-ordination  in  the 
limbs.  The  interference  with  the  function  of  the  posterior 
columns  of  the  cord  may,  in  a  recent  case,  be  out  of  pro- 
portion to  structural  change,  but  in  the  eye  this  is  rare,  and 
the  structural  change  is  that  on  which  our  prognosis  is  based. 
At  the  same  time  an  arrest  of  progress  is  sometimes  obtained, 
as  it  is  in  the  ataxy.  Although  ultimately  almost  all  cases 
increase,  yet  the  progress  is  often  very  slow,  and  many  years 
may  pass  before  even  a  small  field  is  finally  lost.  The 
perimeter  affords  valuable  aid  in  estimating  changes,  which/ 
patients  are  apt  to  regard  too  favourably. 


LATERAL    SCLEROSIS. 


Ophthalmoscopic  changes  are  very  rare  in  cases  which 
present  the  symptoms  of  primary  lateral  sclerosis  of  the 
cord.  In  one  or  two  cases,  however,  I  have  seen  grey 
atrophy  slowly  supervene,  similar  in  character  to  that  met 
with  in  locomotor  ataxy. 

INSULAR  (DISSEMINATED)  SCLEROSIS. 

Amblyopia  occasionally  occurs  in  insular  sclerosis  of  the 
brain  or  cord,  but  very  rarely  goes  on  to  complete  loss  of 


196  MEDICAL   OPHTHALMOSCOPY. 

sight.  It  is  often  unattended  by  the  ophthalmoscopic  signs 
of  atrophy ;  the  examination  is  frequently  difficult  on  account 
of  the  associated  nystagmus.  In  such  cases  the  optic  nerves 
may  be  found  to  be  occupied  by  patches  of  sclerosis,  similar 
to  those  which  occur  elsewhere.1  The  nerve  fibres  passing 
through  are  not  destroyed,  their  axis  cylinders  persist,  and 
retain  impaired  functional  power,  although  their  medullary 
sheath  may  disappear. 

Occasionally,  however,  atrophy  of  the  optic  nerves  is 
observed  in  this  affection  quite  similar  in  its  character  to 
that  seen  in  ataxy,  attended  by  a  similar  loss  of  vision, 
progressing  to  complete  blindness.2  Dr.  S.  H.  Habershon 
found  uniocular  central  scotoma,  absolute  for  white,  red  and 
blue,  in  a  case  of  this  disease.  The  corresponding  optic  disc 
was  greyish  white,  especially  in  its  outer  half.3 


CARIES  OF  THE  SPINE. 

Caries  of  the  spine  in  the  dorsal  region  is  unattended  by 
ocular  changes.  Bull4  has  recorded  an  examination  of  fifty 
oases,  but  the  changes  he  met  with,  confessedly  rare,  are  of 
doubtful  pathological  character,  being  confined  to  fulness  of 
the  retinal  vessels,  and  sometimes  dilatation  of  the  capillaries 
of  the  disc.  When  the  caries  is  in  the  cervical  region,  marked 
congestion  of  the  disc  has  been  described.  In  one  case  under 
my  own  observation  the  discs  were  red,  and  there  was  much 
white  tissue  about  the  vessels,  very  conspicuous  against  the 
red  disc  (as  in  PI.  I.  2),  but  the  margins  of  the  side  were 
quite  clear,  and  the  pathological  nature  of  the  appearance 
was  somewhat  doubtful.  Abadie5  has  recorded  a  case  in 
which  atrophy  of  the  optic  nerves  supervened,  and  attributes 
it  to  meningitis  ascending  to  the  base  of  the  brain,  of  which, 

1  Charcot :  "Le9ons  sur  les  Maladies  du  Systeme  Nerveux,"  t.  i.  p.  206. 

2  Magnan  :  "  Arch,  de  Physiologic,"  t.  ii.  p.  765.     Liouville  :  "Memoires 
de  la  Soc.  de  Biologie,"  1868,  p.  231. 

3  "Trans.  Ophth.  Soc.,"  vol.  ix.  1889,  p.  162. 

4  "  Am.  Journal  of  Med.  Science,"  July,  1875. 

5  "  Bull,  de  la  Soc.  de  Chir.,"  Jan.  12,  1876. 


INJURIES   TO   THE    SPINE.  197 

however,  there  was  no  other  evidence.  In  the  case  of  a  girl, 
aged  fifteen,  suffering  from  Pott's  paraplegia,  who  was  in 
Queen  Square  Hospital,  under  the  care  of  Dr.  Buzzard, 
there  was  well-marked  optic  neuritis.  She  had,  however, 
frequent  severe  headaches,  and  occasional  vomiting,  and  the 
neuritis  did  not  improve  as  the  paraplegia  passed  away,  so 
that  it  is  possible  that  some  intra-cranial  tumour  (?  tubercular) 
co-existed. 


INJURIES  TO  THE  SPINE. 

The  subject  of  the  changes  in  the  optic  discs  in  spinal 
injuries  has  received  a  large  amount  of  attention  in  conse- 
quence of  the  prominence  which  "  railway  cases  "  have  given 
to  this  class  of  accident.  In  its  scientific  relations  the  sub- 
ject has  not  escaped  the  sinister  influence  which  litigation 
exercises  on  the  investigation  of  facts,  and  there  is  no  doubt 
that  the  pathological  nature  of  many  of  the  appearances 
described  in  these  cases  has  been  the  result  of  an  affection  of 
the  mind  of  the  observer,  rather  than  of  the  eye  observed. 
Still,  it  seems  well  established  that  in  some  cases  of  spinal 
injury  ocular  changes  supervene,  and  the  observations  of 
Clifford  Allbutt  especially  show  that  they  occur  with  greater 
frequency  the  higher  up  the  injury  is.  The  changes  are 
those  of  simple  congestion,  congestion  with  oedema,  and  slight 
neuritis,  uniform  redness  of  the  disc,  and  concealment  of  the 
outlines  so  that  the  position  of  the  disc  may  ultimately  be 
recognized  only  by  the  convergence  of  the  vessels.  In  one 
case  a  "  daffodil  colour  "  was  described.  Sight  is  a  little,  but 
not  much  affected,  and  the  condition,  which  is  of  slow  onset 
and  course  (coming  on  some  weeks  after  the  injury),  usually 
passes  away.  A  remarkable  case  of  this  kind  has  been 
described  by  Thorowgood.1  A  girl,  aged  twelve,  after  a 
blow  on  the  lower  part  of  the  back,  complained  of  pain 
and  tenderness  at  the  neck,  with  muscular  stiffness.  A  week 
after  this  some  dimness  of  sight  came  on  and  increased, 

1  '« Clin.  Trans.,"  viii.  1875,  p.  80. 


198  MEDICAL    OPHTHALMOSCOPY. 

until  five  weeks  after  the  blow  sight  was  lost,  and  well- 
marked  optic  neuritis  was  found.  Leeches  and  mercury 
were  employed,  and  the  discs  and  sight  recovered  completely- 
It  has  been  supposed  (especially  by  Mr.  Wharton  Jones) 
that  a  disturbance  of  the  sympathetic  is  the  cause  of  the 
ocular  symptoms  in  spinal  injury.  In  cases  of  actual  disease 
of  the  sympathetic,  however,  no  ophthalmoscopic  change  has 
been  found  (Hughlings- Jackson,  Eiegel,  and  Jolly).  Clifford 
Allbutt  suggests  that  they  may  be  the  result  of  "  meningeal 
irritation "  passing  up  to  the  base  of  the  brain,  but  other 
evidence  of  such  irritation  has  not  been  recognized. 

FUNCTIONAL    DISEASES    OF    THE    NERVOUS    SYSTEM. 
EXOPHTHALMIC    GOITRE. 

The  conspicuous  ocular  symptoms  which  form  part  of 
Graves'  disease  might  lead  to  the  expectation  that  changes  in 
the  fundus  oculi  would  be  found  in  that  affection.  As  a  rule, 
however,  it  is  not  so.  The  prominence  of  the  eyeballs  does 
not  lead  to  any  alteration  in  the  optic  nerve.  The  retinal 
arteries  participate  in  the  general  arterial  dilatation,  which 
occurs  so  uniformly  in  the  disease,  and  is  ascribed  to  a 
paralysis  of  the  sympathetic  vaso-motor  fibres.  The  arteries 
are  larger  than  normal,  and  when  their  course  is  favourable 
for  their  comparison  with  the  veins,  the  two  may  be  observed 
to  be  nearly  equal  in  size,  clearly  in  consequence  of  arterial 
dilatation.  The  strong  pulsation  which  occurs  in  the  arteries 
of  the  head  and  neck,  in  consequence  of  their  dilatation  and 
of  the  excited  action  of  the  heart,  may  be  visible  in  the 
retina  as  a  spontaneous  arterial  pulsation,  as  Becker  first 
pointed  out.  He  has  found  it  in  six  out  of  seven  cases,  and 
remarks  that  it  varies  in  degree,  and  may  at  times  be 
unrecognizable.1 

CHOREA. 

Embolism  of  the  central  artery  of  the  retina  is  an  ex- 
tremely rare  result  of  the  endocarditis  which  is  generally 
found  (post-mortem)  to  be  associated  with  the  disease  in 

1  "  Kl.  Monatsbl.  f.  Augenh.."  Jan.  1880. 


CHOREA.  199 

severe  cases.  Only  two  instances  have  been  recorded ;  the 
best  marked  case  is  that  of  Swanzy,  of  Dublin.1  The 
embolism  occurred  at  the  time  of  the  commencement  of  the 
chorea,  and  was  in  the  left  eye.  The  chorea  was  most  severe 
on  the  left  side.  The  state  of  the  heart  is  not  mentioned. 
The  other  case  is  recorded  by  Forster,  but  was  not  seen  until 
some  time  after  its  occurrence.  The  patient,  a  child,  had 
suffered  from  chorea  for  some  years,  and  during  the  chorea 
had  lost  the  sight  of  one  eye.  The  disc  was  atrophied,  and 
the  arteries  very  small. 

Slight  optic  neuritis  is  not  very  uncommon  in  chorea,  and 
now  and  then  neuritis  of  considerable  intensity  is  seen, 
although  seldom  in  the  degree  comparable  to  that  usually 
met  with,  for  instance,  in  cerebral  tumour.  I  have  twice? 
however,  seen  this  latter  intensity  attained.  In  each  case 
the  patient  was  a  girl  of  seventeen  or  eighteen  years,  and 
in  each  the  neuritis  passed  away  completely  as  the  chorea 
subsided.  These  cases  give  significance  to  the  slighter  forms. 
In  these  the  edge  of  the  disc  is  decidedly  blurred,  sometimes 
only  on  one  side,  sometimes  all  round,  although  not  often  to 
such  an  extent  as  to  prevent  its  position  being  recognized  in 
the  indirect  method  of  examination.  To  the  direct  method 
the  edge  of  the  nasal  side  is  obscured,  necessarily.  The 
swelling  is  slight,  the  physiological  cup  seldom  encroached 
upon,  and  haemorrhages  absent.  In  all  the  cases  in  which  I 
have  met  with  it,  there  has  been  a  recognizable  degree  of 
hypermetropia ;  this  fact  would  lessen  the  significance  of  the 
neuritis  in  regard  to  the  chorea,  were  it  not  that  the  aspect 
of  the  disc,  in  every  case  that  I  have  seen,  has  become  normal 
when  the  chorea  has  subsided.  The  frequency  with  which 
such  an  appearance  is  met  with  is  difficult  to  ascertain ;  in  a 
percentage  probably  of  eight  or  ten  this  is  to  be  seen.  The 
slight  form  is  seen  in  children  chiefly — the  more  severe  in 
girls  about  puberty.  It  is  probably,  when  intense,  a  co- 
incident effect  of  the  state  of  the  blood.  Slight  double  optic 
neuritis  was  seen  by  Hughlings- Jackson  in  a  case  of  hemi- 
chorea,  right-sided.  When  first  observed  the  discs  were 

1  "Ophth.  Hosp.  Rep.,"viii.  181. 


200  MEDICAL   OPH.THALMOSCOPY. 

hypersemic,  badly  margined,  the  veins  large  and  irregular. 
The  change  was  most  marked  in  the  left  eye.  The  appear- 
ance increased  with  the  chorea,  and  disappeared  with 
recovery.  Bouchut  has  figured  white  exudation  on  and 
about  the  disc  in  a  case  of  a  third  attack  of  severe  chorea. 
In  one  case  which  came  under  my  observation  there  was 
also  kidney  disease,  and  ulcerative  endocarditis,  and  slight 
retinal  haemorrhages  were  also  present,  so  that  it  is  certain 
that  the  neuritis  could  not  be  ascribed  wholly  to  the  cerebral 
affection. 

NEURALGIA  AND  MIGRAINE. 

Occasionally  atrophy  of  the  optic  nerve  has  been  observed 
in  cases  of  severe  unilateral  neuralgia  of  the  fifth  nerve.  Its 
origin  is  obscure.  Temporary  amaurosis,  supposed  to  be 
"  reflex,"  is  more  common.  The  transient  disturbances 
of  sight,  temporary  amaurosis,  hemianopia,  &c.,  which 
accompany  migraine,  are  well  known.  In  a  girl,  aged 
eighteen,  blindness  of  the  left  eye  occurred  after  some  days 
of  migrainous  pain.  The  ophthalmoscopic  appearances  were 
normal ;  vision  was  qualitative  only,  and  the  pupil  did  not 
react  to  light.  Treatment  was  without  effect  for  fifty  days ; 
then  chloral  and  quinine  were  given,  and  slight  improvement 
took  place,  probably  not  due  to  the  treatment.  The  slow 
improvement  of  vision  went  on,  and  the  sight  became  good, 
although  the  progress  was  interrupted  by  slight  relapses  due 
to  changes  of  weather  and  mental  excitement. 

Of  greatest  importance,  however,  are  the  attacks  of  loss  of 
sight  lasting  for  a  few  hours  or  a  day  or  two,  occasionally 
observed  in  the  subjects  of  migraine,  apart  from  attacks  of 
headache,  and  at  other  times,  in  association  with  pain. 
This  transient  failure  of  sight  sometimes  remains  permanent, 
always  in  one  eye  only.  The  ophthalmoscopical  appearances 
in  such  cases  are  those  of  occlusion  of  the  central  artery. 
The  state  is  usually  ascribed  to  embolism,  but  it  is  more 
likely  thrombosis.  Gralezowski1  has  recorded  three  such 

1  "Rec.  d'Ophthmal. ,"  Jan.  1882.  See  also  Rampoldi,  "Ann.  di  Ottalmo.," 
1882.  A  case  recently  described  by  Doyne  was  probably  of  this  nature. 
There  had  been  two  attacks  of  transient  blindness  of  one  eye,  in  the  last  of 


IDIOPATHIC   EPILEPSY.  201 

cases  without  heart  disease,  also  one  in  which  slow  atrophy 
occurred  in  one  eye,  and  another  in  which  failure  of  sight 
after  an  attack  of  migraine  was  attended  by  signs  of 
neuro-retinitis,  with  small  haemorrhages  and  thrombosis  in 
some  minute  vessels.  Now  and  then  atrophy  of  the  optic 
nerve  has  been  observed  to  follow  repeated  attacks,  and 
Hutchinson  has  associated  the  three  symptoms  of  migraine, 
amaurosis,  and  xanthelasma.  Glaucoma  is  sometimes  ob- 
served in  cases  in  which  there  has  been  long-standing 
liability  to  unilateral  neuralgia  of  the  fifth  nerve.  It  has 
been  proved  that  irritation  of  the  fifth  nerve  may  increase 
the  intra-ocular  tension.1 

IDIOPATHIC  EPILEPSY. 

Inter-paroxysmal  State. — In  idiopathic  epilepsy  the  appear- 
ance of  the  fundus  oculi  between  the  paroxysms  is,  as  a  rule, 
normal.  Some  observers  have  described  changes  in  the  optic 
discs,  and  increased  vascularity,  distended  retinal  vessels,  and 
the  like.  I  have  examined  very  carefully  about  a  thousand 
epileptics,  and  have  found  that  in  most  cases  every  character 
of  the  fundus  was  such  as  is  presented  by  persons  not 
epileptic.  Now  and  then  an  unduly  red  disc  is  to  be  seen, 
but  not  more  frequently  than  in  persons  not  epileptic,  and  in 
most  cases  it  is  explicable  by  the  ocular  conditions — a  point 
too  little  attended  to  in  medical  ophthalmoscopy.  The  only 
deviation  from  the  normal  state  of  the  fundus  which  has 
seemed  to  me  frequent,  is  an  unusual  equality  in  size  of 
the  retinal  arteries  and  veins.  The  latter  are  not,  as  a 
rule,  larger  than  normal,  and  the  arteries  appear  as  if 
large  from  a  lax  state  of  wall.  Spontaneous  pulsation  in 
the  veins  has  been  described  by  Kostl  and  Niemetschek2 
as  especially  frequent  in  epileptics :  it  is  certainly  not 

which  the  upper  half  of  the  retina  was  found  to  be  cedematous.  The  ascend- 
ing arteries  ultimately  became  narrowed  on  the  disc,  and  the  lower  part  of 
the  field  remained  defective  after  several  months. — "Trans.  Ophth.  Soc.," 
vol.  ix.  p.  148. 

1  Hippel  and  Griinhagen  :  "  Arch.  f.  Ophth.,"  vols.  xiv.  and  xvi. 

2  "Prager  Vierteljahreschr.,"  vols.  cvi.  and  cvii. 


202  MEDICAL    OPHTHALMOSCOPY. 

more  frequent  in  them  than  in  individuals  who  are  not 
epileptic. 

During  the  paroxysm  the  appearance  of  the  fundus  has 
been  described  variously  by  different  observers.  For  obvious 
reasons,  the  difficulties  in  the  examination  are  great,  and 
opportunities  are  rare.  The  only  change  which  seems  well 
established,  is  that  the  retinal  veins,  during  the  stage  of 
lividity,  become  much  distended.  Regarding  the  state  of 
the  arteries,  there  is  considerable  doubt.  On  theoretical 
grounds,  because  contraction  of  the  cerebral  arteries  is 
supposed  to  be  the  immediate  cause  of  a  fit,  it  has  been 
expected  that  contraction  of  the  retinal  arteries  would  also 
be  seen,  and  De  "Wecker  has  described  a  sensible  diminution 
in  the  size  of  the  arteries  during  the  pallor,  but  Kostl  and 
Niemetschek  thought  that  they  recognized  in  one  case 
dilatation  of  the  arteries  during  an  attack.  Observation, 
however,  of  the  size  of  the  vessels  by  the  indirect  method,  is 
of  small  value. 

In  a  case  of  convulsions  from  meningeal  haemorrhage,  in 
which  there  was,  however,  no  initial  pallor  of  face,  and  also 
in  a  case  of  severe  one-sided  fits,  I  have  been  able  to  keep 
a  retinal  artery  and  vein  under  (direct)  view  through  the 
whole  of  a  severe  fit,  from  before  its  commencement  until 
after  its  close.  In  neither  case  did  the  retinal  artery  present 
the  slightest  change  in  size.  During  the  stage  of  lividity, 
the  vein  became  large  and  dark.  In  a  case  of  chronic  local 
meningitis  of  the  motor  region  of  the  left  hemisphere 
(Case  2),  by  galvanizing  the  region  of  the  cervical  sympa- 
thetic, I  was  able  to  produce  the  aura  with  which  the  fits 
commenced,  and  once  watched  the  retinal  vessels  by  the 
direct  method  during  the  operation,  but  no  change  in  their 
calibre  was  to  be  observed,  although  the  aura  was  so  intense 
as  almost  to  pass  into  a  fit.  Clifford  Allbutt,  during  a 
fit,  has  observed  pallor  of  the  discs,  and  a  similar  con- 
dition has  been  seen  by  Hughlings- Jackson  and  Arlidge,1 
immediately  after  a  fit,  in  several  cases.  During  an  attack 
of  epileptiform  amaurosis,  Dr.  Jackson  failed  to  see  any 
1  "  West  Riding  Asylum  Reports,"  vol.  i. 


1DIOPATHIC   EPILEPSY.  203 

change  in  the  fundus  which  he  was  at  the  time  comparing 
with  a  drawing  of  it.  After  a  second  attack  the  veins  appeared 
a  little  paler  than  before.1  I  have  repeatedly  examined 
patients  immediately  after  fits,  but  without  being  able  to 
satisfy  myself  that  there  was  any  difference  from  the  appear- 
ance of  the  disc  and  vessels  at  other  times.  It  is  possible  that, 
as  Knies2  has  suggested,  changes  in  the  size  of  the  vessels 
sometimes  described,  may  be  due  to  a  sudden  alteration  in 
the  intra-ocular  pressure  from  changes  in  the  accommodation. 

In  cases  of  epilepsy  in  which  the  fits  were  frequent,  Clifford 
Allbutt  has  seen  hypersemia  of  the  discs,  and  even  some 
exudation  into  them.  As  a  rule,  my  own  observations 
have  given  quite  negative  results.  In  one  case,  however, 
I  met  with  marked  changes  in  the  discs,  developed  under 
observation  during  a  series  of  exceedingly  severe  convulsive 
attacks,  recurring  at  short  intervals  for  several  days.  The 
patient  was  a  young  man,  and  the  convulsions  were  of 
hysteroid  type — paroxysms  of  struggling,  arching  of  back, 
throwing  about  of  head  and  limbs,  so  intense  that  the  united 
strength  of  three  or  four  persons  was  required  to  keep  the 
man  in  bed.  They  were  accompanied  by  loss  of  conscious- 
ness. Bromide  and  other  remedies  produced  no  effect,  and 
the  convulsions  continued  unabated  until  ice  was  applied  to 
the  cervical  spine,  when  the  attacks  at  once  ceased.  The 
optic  discs,  after  some  days  of  convulsion,  became  reddened 
and  veiled,  so  that  their  edges  were  quite  invisible,  and  there 
was  distinct  swelling.  After  the  cessation  of  the  fits  the  discs 
gradually  resumed  their  normal  appearance.  This  patient, 
about  three  months  later,  died,  after  a  series  of  true  epilepti- 
form  convulsions  beginning  in  the  left  hand.  Post-mortem, 
no  trace  of  disease  was  visible  in  the  brain  to  naked-eye 
examination. 

It  might  be  expected  that  the  retinal  vessels  would  often 
give  way  during  the  violent  venous  stasis  of  an  epileptic  fit, 
just  as  do  those  of  the  conjunctiva.  As  already  stated,  retinal 
haemorrhage  is  rarely  observed  under  the  circumstances,  no 

1  "  Lancet,"  Feb.  17,  1874. 

2  "  Sitzungsbericht  der  Heidelberg  Ophth.  Gesellsch.,"  1877,  p.  61 


204  MEDICAL   OPHTHALMOSCOPY. 

doubt  on  account  of  the  support  afforded  to  the  walls  of  the 
vessels  by  the  intra-ocular  tension. 

It  must  be  remembered  that  many  cases  of  apparently 
idiopathic  epilepsy  may  present  traces  of  old  optic  neuritis 
or  choroiditis — indicative,  the  former  certainly,  the  latter 
probably,  that  the  convulsions  originated  in  organic  brain 
disease ;  the  choroiditis  indicating  former  syphilis.  Traces  of 
old  optic  neuritis  are  especially  common  in  cases  of  epilepsy 
due  to  blows  on  the  head.  It  must  also  be  remembered  that 
chronic  convulsions  resembling  idiopathic  epilepsy  may  occur 
in  the  subjects  of  lead-poisoning  and  chronic  renal  disease,  in 
each  of  which  optic  papillitis  may  be  present. 

HYSTERIA. 

Although  functional  disturbances  of  sight  (single  or  double 
amblyopia,  hemianopia,  colour-blindness,  often  with  pain  on 
use  of  the  eyes),  occur  occasionally  in  the  hysterical,  ophthal- 
moscopic  changes  are  very  rare.  Atrophy  of  the  optic  nerve 
has  been  met  with  in  one  or  two  cases,  but  was  probably  an 
accidental  coincidence;  or  there  may  have  been  co- existent 
organic  disease,  such  as  disseminated  cerebro-spinal  sclerosis, 
underlying  the  manifestations  of  hysteria.  When  there  is 
extreme  amblyopia,  dilatation  of  vessels  and  serous  transuda- 
tion  into  the  retina  have  been  seen  by  Landolt.  The  chronic 
perineuritis  described  by  Gralezowski  in  one  case  must  be 
regarded  as  altogether  exceptional.  In  hystero-epilepsy 
also  there  are,  as  a  rule,  no  ophthalmoscopic  changes,  but 
after  extremely  severe  and  repeated  fits,  slight  alteration 
may  be  met  with,  as  in  the  case  described  in  the  section 
on  "Epilepsy." 


INSANITY. 

The  frequency  with  which  pathological  appearances  are  to 
be  recognized  with  the  ophthalmoscope  in  cases  of  insanity 
has  been  very  variously  stated.  The  discrepancy  between 


INSANITY.  205 

observers  is  so  great,  that  it  seems  certain  undue  weight  has 
been  given  by  some  to  appearances  which  are  not  uncommon 
in  normal  conditions.  In  fact  the  ophthalmoscopic  appear- 
ances in  the  insane  seem,  for  some  reason,  to  be  a  favourite 
subject  for  observers  whose  experience  of  normal  eyes  is 
insufficient  to  enable  them  to  estimate  the  significance  of  the 
appearances  seen.  The  observations  in  which  changes  were 
found  in  a  large  proportion  of  the  cases  examined  must 
therefore  be  received  with  considerable  reserve.  As  an 
instance  of  the  different  conclusions  which  have  been  reached 
may  be  cited  the  observations  of  Tebaldi,1  who  found  changes 
in  three-fourths  of  the  cases  examined;  and  of  Schmidt- 
Rimpler,2  who  found  changes  only  in  thirteen  out  of  128 
cases,  and  some  of  the  thirteen  he  considered  as  doubtful. 
An  even  more  striking  instance  of  this  discrepancy  is  afforded 
by  two  observers  of  the  appearances  in  general  paralysis,  one 
of  whom  described  atrophy  as  existing  in  eight  out  of  every 
nine  cases  examined,  while  the  other  found  hypersemia  in 
about  the  same  proportion. 

It  must  be  remembered,  in  estimating  the  significance  of 
the  considerable  changes  sometimes  found,  that  the  cases  of 
"  organic  "  brain  disease,  tumour,  softening,  chronic  menin- 
gitis, and  the  like,  in  which  mental  disturbance  is  prominent, 
occasionally  find  their  way  into  asylums. 

GENERAL  PARALYSIS  OF  THE  INSANE. — This  disease  is 
more  closely  allied  to  some  spinal  degenerations  than  to 
other  forms  of  mental  derangement.  Unequivocal  changes 
in  the  eye  have  been  found  much  more  frequently  than 
in  any  other  form  of  insanity.  Loss  of  sight  has  been 
known  since  the  time  of  Calmeil  as  an  occasional  com- 
plication; but  in  a  considerable  degree  it  is  rare.  Billed 
noted  complete  blindness  in  only  three  out  of  400  cases.3 
The  loss  of  sight  has  been  proved  to  depend  on  grey  atrophy 
of  the  optic  nerves,  similar  to  that  which  occurs  in  spinal 

1  Nagel's  "  Jahresbericht,"  1870,  p.  374,  from  the  "Rivista  Cliiiica,"  1870. 

2  "Ann.  d'Oculist.,"  vol.  Ixxiv.  1875,  p.  267. 

3  "Ann.  Med.-Psychologiques,"  1863. 


206  MEDICAL   OPHTHALMOSCOPY. 

disease.  The  retinal  vessels  have  been  normal  in  size  or 
narrowed  (Magnan).  In  its  slighter  degrees,  it  affects  one 
eye  more  than  the  other,  and  its  occurrence  may  easily  be 
overlooked  unless  the  ophthalmoscope  is  used.  Even  in 
slight  degree  it  is  not  a  very  frequent  symptom.  Gralezowski 
found  it  in  one  only  of  forty  cases  examined.1  Boy,  of 
eighty  cases  very  carefully  examined,  found  commencing 
atrophy,  with  amblyopia,  in  four  only.2  Jehn  found  distinct 
atrophy  in  seven  cases  out  of  forty-seven  :  in  four  double,  in 
three  single.3 

As  in  locomotor  ataxy,  it  may  be  an  early  event,  and  may 
even  precede  the  other  symptoms  of  the  disease.  Magnan 
has  observed  the  affection  of  sight  to  commence  two  and  four 
years  before  the  other  symptoms  of  general  paralysis.  In  a 
case  recorded  by  Nettleship,  grey-white  atrophy  of  the  disc, 
in  a  man  aged  thirty-five,  with  slight  unsteadiness  of  gait, 
was  followed,  nine  months  after  the  onset  of  the  amblyopia, 
by  mental  symptoms  which  developed  into  general  paralysis.4 
Mr.  Nettleship  has  informed  me  that  he  has  since  seen  three 
or  four  similar  cases. 

It  is  said  by  Jehn  and  Boy  that  the  amblyopia  commences 
with  defective  colour- vision,  just  as  it  may  do  in  locomotor 
ataxy.  As  another  point  of  contact  between  the  two  diseases, 
it  is  of  interest  to  note  that  Westphal  has  shown  that  sclerosis 
of  the  posterior  or  lateral  columns  of  the  cord  is  occasionally 
found  in  general  paralysis.  It  has  not  yet  been  ascertained 
whether  atrophy  of  the  optic  nerves  is  especially  common  in 
such  cases. 

Magnan5  has  found  after  death  the  optic  nerves  grey  in 
colour  and  sometimes  reduced  to  a  third  of  their  volume,  and 
the  chiasma  and  optic  tracts  also  atrophied.  The  medullary 
sheaths  of  the  nerve  fibres  had  disappeared ;  the  walls  of  the 
vessels  were  thickened  and  covered  with  nuclei.  The  changes 

1  "  I/Union  Med.,"  vol.  xxxi.  1866,  pi  404. 
3  "These  de  Paris,"  1879. 

3  "  Allg.  Zeit.  f.  Psych,"  xxx.  519. 

4  "Ophth.  Hosp.  Rep.,"  vol.  ix.  p.  178 

B  Quoted  by  Robin:    "  Des  Troubles   Oculaires    dans    les   Maladies  de 
1'Encephale,"  p.  330,  1880. 


INSANITY.  207 

were  most  marked  in  the  circumferential  part  of  the  nerve, 
giving  rise  to  a  zone  of  sclerosis  from  which  thick  connective- 
tissue  septa  extended  into  the  central  part  of  the  nerve, 
limiting  irregular  spaces  containing  degenerated  nerve  fibres. 
Magnan  found  analogous  changes  in  the  motor  nerves  to  the 
eyeball.  He  regards  the  process  as  starting  from  the  walls 
of  the  vessels,  and  as  part  of  a  general  change  in  the  central 
nervous  system,  commencing  in  the  superficial  layers. 

The  atrophy  usually  begins  as  such  in  the  simple  form, 
but  Magnan  and  Clifford  Allbutt  have  described  an  initial 
stage  of  hypersemia — uniform  redness  of  the  optic  discs,  with 
softened  edges.  Leber  and  other  observers  have  failed  to  find 
this.  Well-marked  papillitis  was  found  by  Boy  in  one  case, 
and  in  another  he  observed  small  haemorrhages  along  a  few 
of  the  veins.  Neuritis  was  also  seen  in  one  case  by  Jehn. 
"  Peripapillary  oedema,"  a  "  brownish  circle  around  the 
papilla,"1  was  observed  in  some  cases  by  Magnan  and  Grale- 
zowski.  Uhthoff  found  distinct  hypereemia  and  opacity  of 
the  papilla  in  a  case  in  which  sight  had  failed  in  one  eye 
for  six  weeks  only,  and  was  reduced  to  £  with  concentric 
limitation  of  the  fields  for  white  and  colours.  Voisin 
described  an  undue  tortuosity  and  dilatation  of  the  retinal 
arteries,  while  by  Magnan  and  others  a  grey  or  white  line 
along  the  vessels  was  frequently  observed.  Jehn  described 
the  arteries  as  of  very  small  size  in  some  cases.  Bouchut  has 
figured  aneurisms  of  the  branches  of  the  central  artery  from 
two  general  paralytics.  Most  of  the  cases  I  have  examined 
in  various  stages  of  the  disease  presented  perfectly  normal 
conditions.  In  one  case  only  was  there  the  appearance  of 
simple  congestion  of  the  disc. 

MANIA. — During  a  paroxysm,  Clifford  Allbutt  in  one  case 
found  pale  discs  ;  in  others  the  discs  were  hypersemic. 
Noyes2  described  hypersemia  in  fourteen  and  anaemia  in  six 
out  of  twenty-six  cases.  Dr.  Savage,  formerly  of  Bethlem 

1  The  nature  of  this  appearance  is  questionable.     (Edema  usually  causes  a 
pale  halo  around  the  disc  as  in  PI.  I.  3. 

2  "American  Journal  of  Insanity,"  1872. 


208  MEDICAL   OPHTHALMOSCOPY. 

Hospital,  has  informed  me  that  he  has  noted  pallor  of  the 
discs  in  some  cases,  and  in  others  undue  fulness  of  retinal 
veins,  but  no  other  change.  Of  several  cases  I  have  ex- 
amined, in  one  only  was  there  a  pathological  appearance, 
undue  and  uniform  redness  of  the  discs,  with  distinctly 
softened  edge. 

MELANCHOLIA. — Most  observers  have  reported  the  ophthal- 
moscopic  appearances  in  melancholia  to  be  normal,  and  with 
this  my  own  observations  entirely  agree.  Jehn,  however, 
described  hypersemia  in  some  of  forty  cases  examined,  and  in 
two  there  was  actual  neuritis,  which  he  supposes  to  be  due  to 
meningitis.  Neither  in  mania  nor  melancholia  has  Magnan1 
found  any  change  worthy  of  note. 

DEMENTIA. — In  chronic  dementia,  Dr.  Clifford  Allbutt, 
classing  "  worn  out  lunatics  of  all  sorts "  in  the  category, 
found  changes  in  twenty-three  cases  out  of  thirty-eight — 
in  some  atrophy,  in  others  hyperaemia.  Noyes  found  hyper- 
semia in  two-thirds  of  the  cases  examined,  atrophy  in  none. 
Jehn  and  Klein  could  find  no  change  in  the  discs  in  any 
cases  examined. 

In  acute  dementia  Clifford  Allbutt  found  no  change. 
"  Anaemia  of  the  fundus "  with  "  oedema  of  the  retina 
around  the  disc  "  have  been  described  by  Aldridge.2 

DISEASES  OF  THE  URINARY  SYSTEM. 
BRIGHT'S  DISEASE. 

In  all  forms  of  renal  disease  loss  of  sight  from  uraemic 
poisoning  may  occur.3  Its  characteristics  are  the  sudden 
onset,  completeness,  the  usual  absence  of  ophthalmoscopic 
changes,  excepting  such  as  may  have  before  existed,  the 
preservation  of  the  reaction  of  the  pupil,  and  the  quick  dis- 

1  Quoted  by  Robin,  loc.  cit.  p.  287. 

2  West  Riding  Asylum  Reports,"  vol.  iii. 

3  The  association  of  transient  amaurosis  with  dropsy   after  scarlet  fever 
\vas  noted  in  1812  by  Wells  ("Transactions  of  a  Society  for  the  Improvement 


HEIGHT'S  DISEASE.  209 

appearance  of  the  symptom  when  the  blood-state  is  relieved 
by  purgation  or  diaphoresis. 

To  the  almost  invariable  rule  that  the  ophthalmoscopio 
appearances  are  unaffected  by  uraemia,  a  few  exceptions  have 
been  recorded. .  Thus,  in  a  case  of  ursemic  amaurosis,  slight 
oedema  of  the  papilla,  passing  away  with  the  return  of 
sight,  in  the  course  of  a  few  hours,  was  observed  by  Dobro- 
wolsky.1  Again,  Litten2  has  recorded  a  case  of  granular 
kidney  in  which  frequent  uraemic  attacks  occurred  with 
coma,  convulsions,  and  vomiting.  Characteristic  albuminuric 
retinitis  was  present,  and  a  considerable  amount  of  oedema  of 
the  papilla,  causing  swelling  and  peripapillary  cloudiness. 
During  each  attack  of  ursemic  symptoms  the  swelling  of  the 
papilla  and  the  adjacent  opacity  increased,  and  the  veins 
became  more  tortuous.  After  the  attack  was  over,  the 
changes  resumed  their  usual  degree. 

In  diseases  of  the  kidney  of  considerable  duration, 
the  vessels  of  the  retina  may  present  changes  which  they 
undergo  in  common  with  the  vascular  system  of  the  body 
generally.  The  tendency  to  haemorrhage  which  exists  in 
so  marked  a  degree  in  many  cases  of  chronic  Bright's 
disease  may  lead  to  simple  retinal  haemorrhage.  Lastly, 
considerable  changes  are  often  seen  in  the  retina,  which 
vary  greatly  in  different  cases,  and  are  commonly  described 
by  the  general,  but  not  very  accurate,  term  of  "  retinitis 
albuminurica." 

Vessels. — According  to  my  own  observations,3  in  some 
cases  of  chronic  renal  disease,  especially  of  the  granular 
form,  there  is  to  be  seen  a  notable  diminution  in  size  of  the 
retinal  arteries,  independently  of  the  existence  of  any  special 

of  Medical  and  Chirurgical  Knowledge,"  vol.  iii.).  The  first  observation 
of  actual  changes  in  the  retina  was  made  (post-mortem)  by  Tiirck  in  1850 
("Zeitschrift  der  Wiener  Aerzte,"  No.  4,  1850).  The  microscopical  changes 
were  first  carefully  studied  by  Zencker  ("Arch,  fur  Ophth.,"  ii.  142)  and 
Virchow  ("Arch,  fur  Path.  Anat.,"  x.  1856,  p.  178). 

1  "  Klin.  Monatsbl.  fiir  Augenheilk.,"  March,  1881,  p.  121. 

2  "Charite  Annalen,"  1879,  p.  169. 

3  "  British  Medical  Journal,"  December  9,  1876. 

P 


210  MEDICAL   OPHTHALMOSCOPY. 

retinal  disease.  The  veins  are  in  such  cases  not  larger  than 
the  normal,  but  the  arteries  are  not  more  than  one-half  or 
even  one-third  the  diameter  of  the  veins  (PL  IX.  2),  instead 
of  being  two-thirds  or  three-quarters  the  diameter.  The 
comparison  can  only  be  made,  as  already  stated  (p.  9), 
between  arteries  and  veins  which  run  side  by  side  and 
correspond  in  distribution.  Sometimes  the  arteries  can  be 
seen,  even  by  the  direct  examination,  as  lines  only  (PL  IX. 
4.)  I  have  only  observed  this,  however,  when  papillary 
obstruction  co-existed.  The  size  of  the  arteries  may  then 
be  less  than  is  ever  seen  in  simple  papillitic  obstruction 
without  Bright's  disease.  Very  often,  when  slight  swelling 
of  the  retina  co-exists,  the  arteries  are  invisible  beyond  the 
papilla  (PL  IX.  3,  X.  1),  due  in  part,  I  believe,  to  their 
extremely  small  size.  "When  this  reduction  in  size  exists 
the  pulse  usually  presents  marked  incompressibility.  A  re- 
duction in  size,  in  one  case  of  acute  passing  into  chronic 
Bright's  disease,  was  observed  to  coincide  with  a  very  marked 
increase  in  the  tension  of  the  pulse.  The  contraction  is  not 
visible,  however,  in  all  cases  in  which  the  arteries  are  tense. 
In  the  absence  of  any  cause  for  the  reduction,  it  must  be 
ascribed  to  arteriole  contraction,  and  constitutes  evidence  of 
some  weight  in  support  of  the  view  of  Dr.  Gr.  Johnson,  that 
such  contraction  exists,  and  causes  the  hypertrophy  of  the 
muscular  coat  of  the  artery.  It  is,  as  just  stated,  to  be  seen, 
in  some  cases,  independently  of  any  retinal  disease,  but  is  not 
invariable  even  when  the  tension  of  the  pulse  is  very  high. 
This  may  in  some  cases  be  due  to  degenerative  changes  in 
the  walls  of  the  vessels,  as  in  PL  XII.  1,  in  which  no  con- 
traction can  be  perceived. 

According  to  Brailey  and  Edmunds,1  the  walls  of  the  retinal 
arteries  are  constantly  altered  in  chronic  Bright's  disease, 
even  when  no  abnormal  appearances  can  be  seen  with  the 
ophthalmoscope.  The  thickening  consists  of  a  growth  of 
tissue  which  is  especially  situated  between  the  endothelium 
and  the  rest  of  the  interna.  It  may  progress  even  to  the 
obliteration  of  vessels. 

1  "Trans.  Ophth.  Soc.,"  vol.  i.  p.  44. 


BRIGHT'S  DISEASE.  211 

When  the  retina  is  diseased,  conspicuous  white  lines  are 
sometimes  seen  along  its  vessels,  apparently  due  to  a 
sclerosis  of  the  outer  coat.  I  am  not  aware  that  this  con- 
dition has  been  observed  in  any  case  in  which  the  retina 
was  otherwise  normal.  The  remarkable  appearance  shown 
in  PI.  XII.  1  presents,  however,  a  still  more  extreme  con- 
dition of  perivascular  change.  The  arteries  are,  in  part, 
concealed  by  a  white  opaque  sheath,  ceasing  in  places 
suddenly,  and  presenting  the  normal  vessel  emerging  from 
the  sheath. 

In  the  same  fundus  one  artery  presented  two  small  aneu- 
rismal  dilatations — an  interesting  evidence  of  the  vascular 
degeneration  which  is  a  well-known  consequence  of  chronic 
renal  disease. 

In  the  retinal  capillaries  irregular  dilatations  may  be 
found,  especially  in  cases  of  retinal  degeneration,  as  in 
Fig.  68,  p.  218.  In  this  figure  an  increase  of  the  nuclei 
of  the  capillary  wall  is  seen  in  places,  thickening  it.  It  is 
probable  that  the  degeneration  of  such  nuclei,  and  the 
formation  of  such  aneurismal  dilatations,  are  the  conditions 
which  lead  to  haemorrhages,  which  were  numerous  in  this 
case  (PL  X.  1). 

Hcemorrhagcs  form,  as  will  be  immediately  described,  a 
conspicuous  feature  of  most  cases  of  retinal  disease  in  albu- 
minuria.  Their  common  seat  is  the  nerve-fibre  layer,  in 
which  they  are  striated  and  flame-shaped,  and  often  follow 
the  course  of  the  vessels.  Less  commonly  they  may  occur  in 
other  layers,  and  are  then  rounded  and  irregular.  They  may 
detach  the  retina  from  the  choroid  or  burst  through  into  the 
vitreous.  They  sometimes  occur,  however,  apart  from  other 
retinal  changes,  as  isolated  evidence  of  the  hsemorrhagic 
tendency.  An  instance  of  this  is  shown  in  PL  IX.  1.  The 
retina  which  presented  this  extravasation,  even  up  to  the  time 
of  the  patient's  death,  several  months  later,  showed  no  sign 
of  other  changes.  The  haemorrhages  are  probably  due  to 
the  weakening  of  the  wall  of  the  minute  vessels  (by  such 
changes  as  have  been  just  described),  and  to  the  increased 
intra-vascular  tension,  causes  which  are  the  same  as  those 


212  MEDICAL    OPHTHALMOSCOPY. 

which   give   rise   to   the   extravasation    into    the   brain,    so 
common  in  the  same  cases. 

"ALBUMiNURicE-ETixixis." — The  special  retinal  alterations 
which  occur  in  renal  disease  are  perhaps  the  most  frequent 
ocular  changes  to  come  under  the  notice  of  the  physician. 
They  are  met  with  only  in  chronic  forms  of  renal  disease — 
those  which  are  chronic  from  the  beginning,  or  which  are 
chronic  as  resulting  from  an  acute  attack.  They  have 
been  met  with  in  most  chronic  forms  of  kidney  disease — 
granular  kidneys,  large  white  kidney,  sequential  to  an 
acute  attack,  and  lardaceous  kidney.  They  are  by  far  the 
most  common  in  the  granular  form,  and  least  common 
in  the  lardaceous  kidney.1  The  tendency  to  their  occur- 
rence is  said  to  bear  some  relation  to  the  amount  of  albu- 
men in  the  urine. 

Both  eyes  are  almost  invariably  affected.  Yvert,  how- 
ever, records  a  case2  in  which  recovery  took  place,  where  the 
left  eye  only  was  affected.  The  appearances  were  quite 
characteristic,  with  numerous  haemorrhages.  The  intensity 
of  the  changes  varied  with  the  amount  of  the  albumen.  A 
subsequent  post-mortem  showed  that  the  left  kidney  only 
existed,  and  that  that  was  diseased.  Yvert  assumes  the 
influence  of  reflex  nervous  impressions  as  well  as  of  blood- 
states,  and  quotes  several  cases  in  which  a  blow  on  one 
lumbar  region  caused  anasarca,  limited  to,  or  greater  on, 
that  side.  This  view  receives  some  support  from  a  case 
of  Eales',3  the  sight  of  whose  left  eye  failed  the  day 
after  an  injury  to  his  left  lumbar  region.  Three  weeks 
later  there  were  white  spots  near  the  macula,  along  with 
yellowish  exudation  round  the  disc,  and  slight  papillitis. 
The  albumen  gradually  disappeared,  and  the  eye  became 
perfectly  normal. 

1  It  has   been   said   that  retinal   changes  do  not  occur  with   lardaceous 
disease  of  the  kidney.     Cases  have,  however,  been  recorded  by  Beckmann, 
Traube,   Alexander,   Argyll  Robertson,  and  Bull,   and   one  case   has   come 
under  my  own  observation. 

2  "Rec.  d'Ophthal.,"  1883,  p.  145. 

3  "Trans.  Ophth.  Soc.,"  1885,  p.  126. 


BRIGHT'S  DISEASE.  213 

The  frequency  of  retinal  changes  has  been  variously  stated. 
Published  statistics  vary  between  7  and  33  per  cent.  Eales,1 
in  100  cases  of  chronic  disease,  found  retinal  changes  in  28, 
or  1  in  3J,  and  this  probably  represents  approximately  the 
frequency  with  which  they  are  met  with.  The  variation  in 
the  estimated  frequency  is  doubtless  due  mainly  to  the  rela- 
tion of  retinal  changes  to  the  duration  of  the  disease.  Only 
after  the  kidney  disease  has  been  exerting  its  influence  on 
the  system  for  a  considerable  time,  do  these  changes  occur. 
They  commonly  correspond  in  time  with  the  development  of 
•cardiac  hypertrophy.  This  led  Traube  to  assert  that  the 
hypertrophy  of  the  heart  is  the  cause  of  the  affection  of  the 
retina.  But  the  latter  may  be  found  in  rare  cases,  without 
the  former.2  It  is  not  probable  that  there  is  any  necessary 
connection  between  the  retinal  and  the  cardiac  change,  other 
than  that  both  indicate  a  pronounced  and  prolonged  effect 
of  the  renal  disease  upon  the  system.  It  is  indeed  well 
known  that  the  renal  disease  is  often  first  ascertained  by  the 
discovery  of  the  existence  of  the  ocular  change,  but  this  is 
not  opposed  to  the  fact  just  stated,  since  the  retinal  disease  is 
only  the  earliest  discovered  symptom  in  those  cases  in  which 
the  renal  affection  has  been  insidious  in  its  onset,  and  has 
existed  for  a  long  time,  and  reached  an  advanced  stage,  before 
its  symptoms  obtrude  themselves  upon  the  patient's  notice. 

It  has  been  suggested  that  the  retinal  changes  may  some- 
times precede  the  onset  of  the  renal  affection,  but  all  observed 
facts  concur  in  showing  that  the  relation  above  described  is 
the  invariable  one,  that  renal  disease,  usually  with  more  or 
less  albuminuria,  precedes  the  retinal  affection.  The  only 
cases  in  which  the  retinal  changes  precede  the  albuminuria  are 
rare  examples  of  granular  kidney  disease,  in  which  albumen 
is  absent  from  the  urine  until  a  late  stage  of  the  renal 
affection,  as  in  the  case  of  a  lady,  aged  fifty-seven,  suffering 
from  hemiplegia,  who  came  to  me  with  perfectly  characteristic 
•degenerative  albuminuric  retinitis  in  each  eye.  She  had 
hypertrophy  of  the  heart,  with  strong  aortic  second  sound 

1  "Birmingham  Medical  Review,"  Jan.  1880,  p.  34. 

2  Cf.  Litten,  loc.  cit. 


214  MEDICAL   OPHTHALMOSCOPY. 

and  high-tension  pulse.  Repeated  careful  examination  of 
the  urine,  however,  failed  to  reveal  a  trace  of  albumen,  and 
the  specific  gravity  was  not  low.  There  was  a  family  history 
of  rheumatic  (?)  gout,  and  of  apoplexy.  Two  cases  are  also 
recorded  by  Abadie.  In  one  of  them  there  was  polyuria.1 

The  retinal  changes,  as  a  rule,  occur  only  in  cases  of 
organic  disease  of  the  kidney.  In  forms  of  functional  albu- 
minuria  they  have  not  been  observed,  with  the  exception  of 
some  cases  recorded  by  Eales.2  Of  14  cases  of  young  men 
between  eleven  and  twenty-eight  suffering  from  what  was 
believed  to  be  temporary  functional  albuminuria,  he  found 
retinal  changes  in  5,  white  specks  in  4,  white  patches  in  1. 
This  observation  affords  support,  as  he  points  out,  to  the 
view  that,  in  ordinary  Bright's  disease,  the  retinal  changes 
are  due  to  the  morbid  state  of  the  blood. 

The  retinal  disease  presents  certain  elements  which  are 
variously  combined  in  different  cases.  These  are — (1)  diffuse 
slight  opacity  and  swelling  of  the  retina,  due  to  oedema  of 
its  substance  ;  (2)  white  spots  and  patches  of  various  size  and 
distribution,  due  for  the  most  part  to  degenerative  processes ; 
(3)  haemorrhages ;  (4)  inflammation  of  the  intra-ocular  end  of 
the  optic  nerve ;  (5)  the  subsidence  of  inflammatory  changes 
may  be  attended  with  signs  of  atrophy  of  the  retina  and  nerve. 

In  most  cases  one  or  other  of  these  changes  predominates, 
especially  in  the  early  stage  of  the  affection,  and,  according 
to  the  element  most  conspicuous,  four  types  of  disease  may 
be  distinguished.  These  are — the  degenerative,  the  haemor- 
rhagic,  the  inflammatory,  and  the  neuritic,  according  as  white 
spots  of  degeneration,  extravasations  of  blood,  parenchyma- 
tous  retinal  inflammation,  or  inflammation  limited  to  the 
optic  nerve,  predominate.  It  is,  however,  to  be  observed 
that  degeneration  and  haemorrhage  commonly  accompany 
or  succeed  the  inflammatory  changes,  and  that  forms  are 
often  seen  combining  the  characters  of  these  varieties.  In 
the  typical  degenerative  and  haemorrhagic  forms  the  signs  of 
inflammation  are  inconspicuous  or  subordinate. 

1  "La  Union  Medicale,"  1882,  p.  627. 

2  Loc.  cit.     The  nature  of  the  cases  is  open  to  some  question. 


BRIGHT  8   DISEASE. 


215 


The  degenerative  form  (PL  IX.  2)  is  the  most  common.  It 
commences  usually  without  signs  of  inflammation,  by  the 
appearance  of  small  whitish  spots  on  the  substance  of  the 
retina,  sometimes  near  the  optic  nerve  entrance,  sometimes 
at  a  distance.  They  are  commonly  at  first  soft-edged  and 
rounded,  and  as  they  get  larger  become  irregular.  Grene- 
rally,  small  very  white  spots,  often  punctiform  or  elongated, 
make  their  appearance  around  the  macula  lutea,  arranged 
in  a  radiating  manner,  although  frequently  not  forming  a 
complete  circle.  These  are  sometimes  so  minute  as  to  be 
only  visible  on  careful  direct  examination  ;  sometimes  they 
are  large  and  very  conspicuous,  and  are  often  arranged 
irregularly,  end  to  end,  so  as  to  form  radiating  streaks, 
beyond  which  dots  may  be  scattered  (Fig.  67).  Often  a 
less  intense  and  diffuse  opacity  is  visible  in  tracts  here  and 
there.  Sometimes  the  larger  spots  coalesce  into  white  areas, 
which  may  surround  the  disc. 


FIG.  67  —THE  RETINAL  CHANGES  IN  ALBUMINUKIA. 

A  fan-shaped  group  of  white  spots  radiating  from  the  macula  lutea  ;  small 
arteries ;  slight  papillitis. 


216  MEDICAL   OPHTHALMOSCOPY. 

Haemorrhages,  almost  constant  in  all  varieties,  are 
slightest  in  the  most  chronic  degenerative  forms.  They 
often  are  adjacent  to  the  white  spots  due  to  the  changes 
in  the  nerve  fibres,  and,  lying  for  the  most  part  in  the 
nerve-fibre  layer,  they  have  a  more  or  less  striated  arrange- 
ment, determined  by  the  nerve  fibres,  the  direction  of 
which  the  striae  follow.  Sometimes  linear  haemorrhages 
are  seen.  When  larger,  the  extravasations  are  more  or 
less  flame-shaped.  When  small,  they  often  lie  adjacent  and 
parallel  to  vessels,  but  it  is  not  often  that  the  vessel  from 
which  they  originate  can  be  traced.  When  large  they  may 
be  irregular  in  shape  and  occupy  the  deeper  layers  of  the 
retina. 

The  diffuse  opacity  already  described  is  sometimes  con- 
siderable and  accompanied  by  a  little  swelling  here  and 
there.  Such  a  change  is,  however,  rarely  well  marked  in  the 
form  which  begins  with  simple  degeneration. 

The  retinal  changes  in  this  form  may  be  considerable 
without  any  alteration  in  the  optic  disc.  Often,  however,  its 
edges  become  blurred,  the  physiological  cup  indistinct,  and 
the  tint  abnormal,  reddish-grey. 

In  two  patients  suffering  from  lardaceous  degeneration 
Bull1  observed  the  whole  retina  to  present  a  uniform  whitish 
infiltration,  with  numerous  haemorrhages.  He  suggests  that 
the  appearance  may  have  been  due  to  lardaceous  degenera- 
tion of  the  retina. 

In  the  fmmorrhagic  form,  the  conspicuous  change  is  the 
occurrence  of  a  large  number  of  haemorrhages,  with  but  little 
degenerative  change  and  but  slight  signs  of  inflammation  of 
disc  or  retina.  Commonly,  especially  after  a  time,  there  is 
more  or  less  degeneration  adjacent  to  the  haemorrhages,  and 
traces  of  the  halo  of  spots  around  the  macula  are  rarely 
absent.  The  haemorrhages,  for  the  most  part,  resemble  those 
just  described,  differing  only  in  their  number,  size,  and 
predominance. 

In  the  inflammatory  form  (PL  X.  1)  there  is  a  general 
parenchymatous  swelling  of  the  retina  with  complete  obscu- 
1  "  American  Journal  of  Med.  Science,"  Oct.  1879. 


BRIGHT'S  DISEASE.  217 

ration  of  the  disc.  The  vessels  are  concealed,  the  arteries 
especially.  The  veins  are  distended,  and  sometimes  have  an 
extremely  irregular  and  tortuous  course  over  the  fundus ;  the 
-arteries  are  narrow.  Haemorrhages  invariably  occur  in  con- 
siderable number,  and  are  often  large  and  striated.  White 
spots  are  commonly  numerous,  and  more  or  less  uniform  in 
character,  especially  in  the  acute  cases,  in  which  they  are 
large,  rounded  (as  in  the  figure),  and  soft-edged.  In  these 
cases  there  is  rapid  degeneration  of  the  tissue  elements,  and 
abundant  infiltration  with  lymphoid  cells.  If  the  inflamma- 
tion subsides,  the  signs  of  degeneration  may  become  more 
predominant,  and  the  optic  nerve  may  present  evidence  of 
secondary  atrophy.  I  believe,  however,  that  it  is  rare  for 
any  subsidence  of  this  form  to  occur,  because  it  is  confined  to 
•cases  in  which  the  effect  of  the  renal  disease  on  the  system  is 
intense,  and  usually  soon  leads  to  death. 

Neuritic  Form  (PL  IX.  2,  3,  4). — In  some  cases  the  inflam- 
mation of  the  optic  nerve  predominates  over  the  other  retinal 
•changes  to  such  an  extent  that  it  may  appear  to  be  the  only 
alteration,  'and  may  present  nearly  the  aspect  which  is 
common  in  intra-cranial  disease.  The  edges  of  the  disc  are 
veiled  under  a  greyish-red  swelling,  of  moderate  prominence, 
which  may  extend  a  little  distance  beyond  the  normal  edges 
of  the  disc.  The  prominence  may  be  slight,  or  such  that 
the  veins  form  conspicuous  curves  over  the  sides.  The 
arteries  are  usually  narrow,  and  often  concealed  in  the 
swelling ;  even  the  veins  may  be  concealed.  On  direct 
examination  it  is  generally  conspicuously  striated.  Fre- 
quently, on  the  surface  of  the  swelling,  or  apparently 
beneath  its  surface,  there  is  a  conspicuous  white  reflection 
in  certain  spots  (PL  IX.  2),  most  distinct  on  oblique 
illumination.  Occasionally  on  the  surface  of  the  swollen 
papilla  may  be  very  minute  white  dots  (just  recognizable  in 
PL  IX.  3). 

A  careful  examination  will  show,  in  almost  all  cases,  signs 
of  slight  retinal  degeneration,  sometimes  so  slight  as  to 
require  close  attention  and  careful  focussing  by  the  direct 
method  to  detect  them.  Sometimes,  as  in  PL  IX.  2,  there 


218 


MEDICAL   OPHTHALMOSCOPY. 


FIG.  68. — SECTION  THROUGH  RE- 
TINA IN  A  CASE  OF  ACUTE 
ALBUM  INURIC  RETINITIS. 

The  section  passes  through  one 
of  the  white  spots  near  the 
disc,  shown  in  PL  X.  1.  The 
retina  is  greatly  thickened, 
mainly  from  changes  in  the 
nerve-fibre  layer  (a  a'),  where 
numerous  granular  bodies  are 
seen  (such  as  are  shown  more 
magnified  in  Fig.  69).  Capil- 
laries are  dilated,  with  con- 
spicuous alterations  in  their 
walls  ;  one  of  them  (near  right 
edge  of  figure)  presents  a  series  of 
aneurismal  dilatations  (  x  180). 


are  one  or  two  white  spots  in 
the  retina,  near  the  neuritic 
swelling.  At  others,  as  in  PL 
IX.  3,  4,  minute  white  spots 
are  to  be  detected  near  the 
macula  lutea.  Frequently  small 
haemorrhages  are  to  be  seen 
somewhere  about  the  fundus 
(PI.  IX.  4).  It  is  remarkable 
that  there  is  little  tendency 


FIG.  69. 

PRODUCTS  OF  DEGENERATION  FROM 
A  WHITE  PATCH  IN  A  CASE 
OF  ALBUMINURIC  RETINITIS. 
(x  250.) 


FIG.  70. 
DEGENERATED  FIBRES  OF  MULLEK 

FROM   A  CASE  OF  ALBUMINURIC 

RETINITIS. 
Swelling  of  the   ends   of  the  fibres, 

and  rows  of  fatty  granules  due  to- 

degeneration.     (  x   250. ) 


BRIGHT  S   DISEASE. 


219 


for  haemorrhages  to  occur  in  the  swollen  papilla  in  this  form. 
If  the  neuritis  subsides,  a  condition  of  consecutive  atrophy 
may  be  left — a  filled-in  disc,  greyish,  with  paler  lines  along 
the  vessels,  and  often  extremely  small  arteries.  Such  a  con- 
dition is  shown  in  PI.  IX.  4. 

Anatomical  Changes. — The  scattered  white  spots  depend 
commonly  on  degeneration  of  the  layer  of  nerve  fibres,  which 
are  found  to  be  greatly  thickened.  The  fibres  often  present 
varicosities,  which  may  attain  a  large  size  and  become 
crammed  with  fat-like  globules.  These  ultimately  become 
isolated  as  large  fat-containing  spheres,  which,  with  free 
globules  of  fatty  matters,  are  found  abundantly  on  micro- 
scopical examination  of  recent  specimens  (Figs.  69,  70), 
and  are  very  conspicuous  in  a  surface  view  (Fig.  71). 
The  degeneration  occurs  also,  and  sometimes  chiefly, 
in  the  deeper  layers,  which  may  also  be  infiltrated 


FIG.  71. — SURFACE  VIEW  OF  A  WHITE  SPOT  ON  THE  RETINA  IN 
ALBUMINURIC  RETINITIS. 

The  transverse  lines  indicate  the  nerve  fibres.  Among  these  are  large  and 
small  oil  globules  and  spherules  consisting  of  similar  still  smaller 
globules.  (After  Pagenstecher  and  Genth.) 


220  MEDICAL   OPHTHALMOSCOPY. 

with  the  "  compound  granule  cells."  Degeneration  of 
other  retinal  elements,  round  corpuscles,  and  vertical  fibres 
of  Muller  may  sometimes  be  found.  The  latter  are  swollen 
and  contain  minute  oil  globules  (Fig.  70).  When  swollen 
they  have  an  undue  refraction,  and  have  been  said,  rather 
unnecessarily,  to  be  "  sclerosed."  It  is  to  the  position  of 
these  that  the  stellate  zone  of  spots  around  the  macula  is 
mainly  due.  The  fibres  here  have  a  less  vertical  direction, 
radiating  from  the  fovea  centralis,  and  the  degeneration  of 
these  fibres  and  the  grouping  by  them  of  the  degeneration 
of  other  retinal  elements  produces  the  radiating  group  of 
spots,  most  conspicuous  near  the  margin  of  the  fovea,  where 
the  fibres  become  placed  more  closely  together.  The  diffuse 
opacity  of  the  retina  is  in  part  due  to  oedema.  The  elements 
of  the  nerve- fibre  layer  may  be  separated  by  clear  spaces, 
and  similar  spaces  may  form  in  the  ganglion-cell  layer,  in 
the  molecular  and  even  in  the  nuclear  layers.  In  this  con- 
dition the  ganglion  cells  often  fall  out  of  the  section  (Fig.  72). 
The  diffuse  opacity  is  also  partly  due  to  an  infiltration  of 
the  retinal  interspaces  with  a  coagulable  fluid,  which,  after 
hardening  processes,  presents  an  appearance  of  interlacing 
fibrillee  with  granules  at  their  points  of  intersection.  This 
may  occupy  large  areas,  as  in  Fig.  68,  especially  in  the 


FIG,  72. — SECTION  THROUGH  THE  RETINA,  SOME  DISTANCE  FROM  THE 
Disc,  IN  A  CASE  OF  ALBUMINURIC  RETINITIS,  SHOWING  (EDEMA. 

The  nerve-fibre  layer  (a)  is  normal,  but  in  the  nerve-cell  layer  (b)  the  gang- 
lion-cells have  fallen  out,  owing  to  the  formation  of  spaces  round  them 
in  consequence  of  the  cedema.  The  other  layers  show  a  tendency  to 
dissociation  of  their  constituents,  and  to  the  formation  of  spaces  here 
and  there.  (  x  150.) 


BRIGHT'S  DISEASE.  221 

outer  molecular  layer,  where  cavities,  containing  this  sub- 
stance and  separated  by  the  remains  of  the  vertical  fibres, 
may  alone  be  perceptible.  A  similar  effusion  may  also 
separate  the  "  membrana  limitans  interna "  and  bases  of 
Miiller's  fibres  from  the  rest  of  the  nerve-fibre  layer. 
Occasionally  the  layer  of  rods  and  cones  presents  remarkable 
thickening,  such  as  is  shown  in  Fig,  68,  and  is  sometimes 
seen  in  other  morbid  states  of  the  retina.  Liebreich  has 
called  attention  to  the  occurrence  of  small  angular  grey  spots 
of  pigment,  often  arranged  in  groups,  and  appearing  first  in 
the  periphery.  They  are  due  to  changes  in  the  pigment- 
epithelium,  and  are  seen  especially  in  cases  in  which  a 
parenchymatous  inflammation  has  passed  away. 

Choroidal  Changes. — Occasionally,  although  rarely,  choroidal 
haemorrhage  may  occur  in  Bright's  disease,  and  may  lead  to 
circumscribed  atrophy  of  the  choroid  with  adjacent  pig- 
mentary disturbance.  A  peculiar  "  colloid  "  degeneration  of 
the  vessels  of  the  choroid  in  old  cases  of  albuminuric  retinitis 
has  been  figured  by  Poncet.  It  leads  to  a  thickening  of  the 
tissue  of  the  choroid. 

Symptoms. — In  the  slighter  forms  of  the  degenerative, 
hsemorrhagic,  and  neuritic  varieties,  vision  may  be  unaffected. 
More  considerable  alteration,  and  even  slight  parenchy- 
matous inflammation,  commonly  entails  amblyopia,  without 
limitation  of  the  field  or  changes  in  colour- vision.  In  rare 
cases  colour-vision  may  be  affected.  As  the  changes  pro- 
gress, the  interference  with  vision  increases.  When  the 
macula  lutea  is  damaged,  central  vision  is  lost,  but  this  is  not 
common.  Degenerative  changes  rarely  reach  the  centre  of 
the  macula,  no  doubt  because  the  structures  in  which  the 
degeneration  occurs  do  not  extend  to  the  f ovea  centralis  itself. 
Haemorrhages,  from  the  paucity  of  large  vessels,  are  also  rare- 
in  this  situation.  The  haemorrhage  may,  however,  encircle 
the  macula,  and  cause  an  annular  defect  in  the  field.  With 
a  central  loss  of  sight,  some  adjacent  colour-blindness  was 
found  by  Gralezowski.  Sight  is  rarely  altogether  lost. 
Attacks  of  uraemic  amaurosis  often  accompany  and  compli- 
cate the  amblyopia  due  to  the  retinal  disease. 


222  MEDICAL   OPHTHALMOSCOPY. 

Pathology. — We  know  little  of  the  relation  between  the 
renal  and  the  retinal  affection.  The  degenerative  changes 
have  been  ascribed  to  the  tendency  to  fatty  degeneration 
which  renal  disease  entails ;  but  this  scarcely  explains  their 
localization  in  the  retina.  Some  facts,  however,  seem  to 
show  that  a  careful  recent  microscopic  examination  of  the 
nervous  tissues  elsewhere  may  reveal  the  occurrence  of 
similar  changes  in  them.  We  know,  especially  through  the 
researches  of  Grull  and  Sutton,  that  an  extensive  increase 
in  the  supporting  tissue  of  the  nerve  centres  may  be 
found  in  chronic  Bright's  disease,  and  the  thickening  in 
the  supporting  tissue  of  the  retina  may  be  part  of  this 
•change.  Knob-like  degenerations  of  the  nerve  fibres  have 
also  been  found  elsewhere  in  the  nervous  centres. 

The  facts  stated  on  p.  214  render  it  probable  that  the 
mechanism  by  which  renal  disease  excites  the  retinal  changes 
is  the  altered  state  of  the  blood. 

The  haemorrhages  have  been  ascribed,  with  reason,  to  the 
double  effect  of  the  degeneration  in  the  minute  vessels  and 
the  increased  arterial  pressure  from  the  cardiac  hypertrophy. 
It  has  been  speculated  that  the  neuritis  may  be  due  to  the 
effusion  of  serum  into  the  sheath  of  the  optic  nerve,  but  the 
view  rests  on  no  post-mortem  evidence. 

In  several  cases  in  which  I  have  found  neuritis  predomi- 
nating, symptoms  of  cerebral  disturbances  were  conspicuous, 
intense  headache,  delirium,  convulsions,  due  apparently  to 
the  effects  of  the  blood-state.  It  seems  probable  that  in  these 
oases  there  is  much  cerebral  disturbance,  and  that  this  may 
determine  the  occurrence  of  the  excessive  change  in  the  optic 
nerve. 

Complications. — Detachment  of  the  retina  is  an  occasional, 
although  not  frequent,  accident.  It  may  be  double  and 
extensive,  as  in  one  case  under  my  own  observation.  The 
whole  retina  was  detached  in  a  case  recorded  by  Davidson.1 
It  is  apparently  due  to  serous  effusion  between  the  retina  and 

1  "Trans.  Ophth.  Soc.,"  vol.  i.  p.  57;  see  also  vol.  viii.  p.  141,  where 
Dr.  Anderson  relates  a  case  in  which  very  extensive  retinal  detachment 
occurred  in  both  eyes  of  a  child  with  chronic  interstitial  nephritis 


BRIGHT'S  DISEASE.  223 

€horoid.  An  example  of  it  in  slight  degree  is  figured  in 
Fig.  68,  which  shows  that  the  pigment-epithelium  may  be 
detached  with  the  retina. 

Hcemorrhage  into  the  vitreous  occasionally  occurs  from  the 
rupture  of  an  extensive  extravasation  in  the  superficial  layers 
of  the  retina.  It  is  always  single,  and  may  occur,  as  in  a 
case  under  my  observation,  without  the  patient's  knowledge. 
One  day  the  f undus  was  distinct,  and  vision  good ;  the  next 
nothing  but  a  black  reflection  from  the  interior  of  the  eyeball 
could  be  seen,  and  sight  was  lost.  It  is  hardly  necessary  to 
say  that  damage  to  vision  may  be  permanent.  It  may 
probably  occasionally  determine  glaucoma. 

Embolism  is  said  to  be  an  occasional  complication  of  albu- 
minuric  retinitis  (Yoelcker).  But  this  statement  must  be 
accepted  with  considerable  reserve.  Embolism  elsewhere  is 
extremely  rare.  Thrombosis  sometimes  occurs  in  the  cerebral 
arteries,  and  the  signs  of  embolism  may  have  been  due  to 
that  cause,  and  on  the  other  hand  the  contraction  of  the 
retinal  arteries  may  simulate  that  in  embolism  ;  but  there  is 
no  corresponding  defect  of  the  field  of  vision  in  these  cases, 
such  as  would  certainly  have  been  present  if  embolism  or 
thrombosis  existed.  As  I  have  suggested,  the  explanation 
of  these  appearances  which  seems  most  probable  is  that  the 
tendency  to  arterial  contraction,  which  is  often  traceable 
in  normal  arteries  in  this  disease,  leads  to  an  extreme  degree 
of  narrowing  when  the  changes  in  the  disc  lessen  the  flow 
of  blood  into  the  arteries. 

Course. — In  most  cases  the  retinal  changes  persist,  some 
lessening,  others  increasing,  until  the  patient's  death.  Not 
rarely,  however,  they  diminish  notably,  and  the  retrogression 
may  proceed  until  the  changes  almost  or  quite  disappear. 
This  is  especially  the  case  when  the  affection  comes  on  in 
the  course  of  the  chronic  kidney  disease  which  results  from  an 
acute  attack,  in  which  considerable  improvement  in  the  renal 
affection  is  often  obtained,  and  in  other  chronic  cases  when 
prompt  treatment  soon  after  the  onset  of  the  retinal  disease 
can  improve  the  action  of  the  kidneys.  The  effect  of  purgation 
in  lessening  the  retinal  affections  has  been  often  observed,  and 


224  MEDICAL    OPHTHAI.MOSCOPY. 

Eales  has  remarked  that  constipation  appears  to  increase 
the  tendency  to  their  recurrence  or  relapse.  Improvement 
is  often  noted  in  the  albuminuria  of  pregnancy,  a  form 
very  prone  to  lead  to  retinal  changes,  which  commonly 
improve  or  even  disappear  when  the  pregnancy  is  over. 
The  greatest  improvement  is  obtained  in  the  cases  of  slight 
papillitis.  Haemorrhages  constantly  disappear,  and,  if  the 
formation  of  fresh  ones  can  be  prevented,  considerable 
improvement  in  the  retinal  state  may  result.  Even  the 
degenerative  changes  may  pass  away,  especially  those  which 
depend  on  the  presence  of  the  granular  bodies  in  the  layer 
of  nerve  fibres.  Most  of  the  white  spots  shown  in  PI.  X.  2 
disappeared.  The  most  persistent  changes  are  those  which 
result  from  the  degeneration  (or  sclerosis  ?)  of  the  fibres  of 
Miiller.  The  white  specks  around  the  macula  lutea,  which 
result  from  this  cause,  rarely  disappear.  Occasionally  re- 
missions in  the  retinal  affection  are  observed,  although  the 
kidney  disease  progresses.  Thus  in  Litten's  case,  referred 
to  on  p.  209,  there  was  repeated  subsidence  of  the  retinal 
change,  in  spite  of  rapid  progress  of  the  renal  affection. 
There  was  not  only  resorption  of  extravasation,  but  also 
disappearance  of  white  patches. 

Diagnosis. — The  recognition  of  the  degenerative  changes 
in  the  retina  is  only  a  matter  of  difficulty  when  the  changes 
are  slight  and  limited  to  the  region  of  the  macula.  The 
strong  contraction  of  the  pupil,  when  this  part  is  examined, 
very  often  renders  the  use  of  homatropine  indispensable  for 
a  thorough  exploration. 

The  aspect  of  the  degenerative  form  is  most  closely  simu- 
lated by  the  retinal  degeneration  which  results  from  a  neuro- 
retinitis  of  wide  extent  (PL  VIII.  2).  It  is  probable,  indeed, 
that  the  changes  are,  to  a  considerable  extent,  identical.  The 
damage  to  and  between  the  radiating  fibres  around  the 
macula  lutea  may  leave  a  stellate  group  of  shining  spots 
quite  indistinguishable  from  those  which  occur  in  renal  disease, 
and  the  diffuse  white  areas  nearer  the  disc  may  also  resemble 
those  seen  in  the  latter  form.  If  the  patient  have  come 
under  observation  during  the  acute  period  of  the  inflamma- 


BRIGHT  S   DISEASE. 


225 


tion,  there  will  be  no  question  as  to  the  nature  of  the  retinitic 
change.  It  will  be  seen  that,  as  in  PL  VIII.  1,  the  neuritic 
swelling  reaches  as  far  as  the  neighbourhood  of  the  macula, 
and  that  the  development  of  the  white  spots  around  the  latter 
is  part  of  the  changes  in  the  retina  occurring  near  to,  and 
evidently  excited  by,  the  inflammation.  If,  however,  the 
patient  come  under  observation  at  a  later  stage,  the  distinc- 
tion may  be  less  easy.  This  is  especially  the  case  when  a 
neuritis  from  a  cerebral  tumour  has  been  unnoticed  till  the 
loss  of  sight  which  accompanies  its  subsidence. 

The  signs  of  one  or  the  other  classes  of  disease — encephalic 
affection  or  renal  disease — are  usually,  however,  sufficiently 
clear  to  leave  little  doubt,  after  a  general  survey  of  the 
symptoms.  But  this  does  not  always  afford  so  clear  a  guide 
as  might  be  expected.  A  cerebral  tumour  may  be  accom- 
panied by  a  trace  of  albumen  in  the  urine.  This  was  the 
case  in  a  child  whom  I  saw  some  years  ago  with  the  late 
Dr.  Anstie.  The  only  symptoms  were  headache,  the  retinal 
changes,  and  the  trace  of  albumen.  On  the  other  hand 
there  may  be  no  symptoms  of  intra-cranial  disease,  except 


J 


FIG.  73. — PAPILLO-RETINITIS. 

From  case  of  cerebral  tumour,  with  appearances  at  macula   closely  reseni 
bling  those  common  in  albuminuric  retinitis.     (After  Edmunds.)1 
1  See  "Trans.  Ophth.  Soc.,"  vol.  iv.  p.  291  and  pi.  7. 

0 


226  MEDICAL    OPHTHALMOSCOPY. 

headache,  which  can,  alone,  hardly  be  regarded  as  such,  and 
may  accompany  the  neuritis  of  albuminuria,  as  in  the  case 
of  the  patient  whose  eye  is  shown  in  PL  IX.  3.  Lastly,  a 
neuritis,  primary  in  the  eye,  may  occur  after  diseases,  as 
scarlet  fever,  which  are  liable  to  be  attended  with  albuminuria. 

But  attention  to  the  following  points  will,  in  most  cases — 
I  think  in  all  cases — enable  a  correct  diagnosis  to  be  made 
by  the  ophthalmoscopic  signs  alone,  or  in  conjunction  with 
the  other  symptoms.  In  the  first  place,  there  are  always 
present  the  signs  of  a  considerable  preceding  neuritis. 
Commonly,  at  the  time  the  failure  of  sight  calls  attention 
to  the  eye,  and  the  white  spots  are  discovered,  there  is  a 
prominent  pale  swelling  over  the  disc,  as  in  PI.  VI.  3.  It 
is  very  rare  for  albuminuric  neuritis  to  leave  a  swelling 
of  this  prominence  and  pallor.  If  atrophy  results  from  an 
albuminuric  neuritis,  the  disc,  by  the  time  it  becomes  pale, 
is  very  little  above  the  retinal  level,  as  in  PI.  IX.  4.  More- 
over, the  neuritic  form  never  occurs,  at  least  as  far  a& 
recorded  facts  and  my  own  observation  have  gone,  except  in 
cases  of  advanced  chronic  renal  disease,  commonly  of  con- 
tracting kidney,1  in  which  the  signs  of  Bright's  disease  are 
always  obvious  enough.  (Regarding  these  distinctions,  see 
also  pp.  96 — 98.) 

In  the  degenerative  changes  of  neuro-retinitis,  of  such  an 
extent  as  to  simulate  closely  the  appearance  of  the  albumi- 
uuric  form,  as  in  PI.  VIII.  2,  all  the  features  of  the  change 
are  those  of  past,  retrogressive  mischief.  The  disc  is  atro- 
phied, the  arteries  evidently  compressed,  and  there  are,  as 
a  rule,  no  hemorrhages.  In  the  renal  form,  of  corresponding 
extent,  there  are  always  signs  somewhere  of  active  progress. 
The  disc  is  commonly  still  inflamed,  and  there  are  usually 
haemorrhages.  Lastly,  when  the  retinal  degeneration  is 
present  as  a  consequence  of  neuritis,  at  the  time  any  diffi- 
culty in  diagnosis  might  arise,  sight  is  almost  always 
lost.  Whereas  complete  loss  of  sight  is  an  event  of  great 
rarity  in  the  albuminuric  form. 

1  In  one  case  I  have  seen  it  in  the  late  stage  of  the  large  pale  kidney, 
in  which  induration  was  commencing. 


DIABETES.  227 

The  form  in  which  haemorrhages  and  spots  of  degeneration 
are  combined,  may  resemble  closely  the  changes  in  the  retina 
in  pernicious  anaemia.  But  in  the  latter  the  perimacular 
circle  is  commonly  not  recognizable,  and  the  degeneration 
is  for  the  most  part  connected  with,  and  secondary  to,  the 
retinal  haemorrhages.  The  degeneration  does  not  attain  the 
same  extent,  and  the  disc  is  usually  unaffected.  The  same- 
remarks  apply,  in  the  main,  also  to  leucocythsemic  retinitis. 
In  the  latter,  the  white  spots  are  much  more  common  in  the 
peripheral  portions  of  the  retina  than  they  are  in  the  renal 
form,  and  in  the  latter  it  is  very  rare  to  see  the  circular  spots,, 
surrounded  by  a  halo  of  haemorrhage,  which  are  so  frequent 
in  leucocythaemia.  In  the  latter  the  tint  of  the  fundus  is- 
commonly  very  different  from  that  in  albuminuria.  In  both 
pernicious  anaemia  and  leucocythaemia  the  independent 
symptoms  of  the  malady  usually  leave  little  room  for  doubt 
as  to  the  nature  of  the  retinal  changes,  but  it  must  be- 
remembered  that,  in  the  latter  especially,  renal  degeneration 
is  often  present. 

Prognosis. — Considerable  attention  has  recently  been 
drawn  to  the  unfavourable  prognosis  as  regards  life  in  cases 
of  chronic  renal  disease  with  retinal  changes.  Such  patients 
seldom  live  two  years,  and  a  large  percentage  of  them  die 
within  a  few  months,1  after  the  retinal  affection  is  observed. 

Treatment. — Local  treatment  is  of  doubtful  value,  (rood 
can  only  be  effected  by  improvement  in  the  blood-state, 
especially  that  which  is  produced  by  purgation  and  dia- 
phoresis. By  this  means  considerable  improvement  may 
often  be  effected  in  the  retinal  disease.  In  several  cases,, 
however,  the  albuminuric  spots  have  entirely  disappeared 
while  under  observation,  although  the  patient  died  from  the 
renal  affection. 

DIABETES. 

DIABETES  MELLITUS. — Defects  of  sight   are   common  in 
diabetes  (as  Bouchardat  pointed  out  many  years  ago),  but 
changes  in  the  fundus  oculi  are  rare.      The  most  frequent 
1  See  Miles  Miley,  "  Trans.  Ophth.  Soc.,"  vol.  viii.  p.  132. 


228  MEDICAL   OPHTHALMOSCOPY. 

cause  for  the  defect  is  cataract,  which  is  apt  to  occur  in 
these  cases.  Occasionally,  considerable  amblyopia  occurs 
without  ophthalmoscopic  changes,  probably  due  to  the  blood- 
state  and  comparable  to  uraemic  amaurosis,  although  pro- 
bably the  result  of  a  different  condition  of  blood. 

Simple  atrophy  of  the  optic  nerve  has  been  observed  in 
some  cases. 

In  a  few  cases  a  central  scotoma  for  white  and  colours 
has  been  observed,  peripheral  vision  being  normal.  The 
symptom  thus  closely  resembles  that  which  results  from 
tobacco,  but  in  some  of  the  cases  this  cause  could  be  with 
certainty  excluded.  Examples  of  this  affection  have  been 
recorded  by  Bresgen,1  Samelsohn,2  and  by  Nettleship  and 
Edmunds.3  The  latter,  in  one  of  their  cases  (in  which  the 
loss  was  chiefly  for  red)  found  atrophy  of  nerve -fibres,  with 
increase  of  nuclei  and  connective  tissue,  in  a  tract  which, 
at  the  back  of  the  orbit,  occupied  the  axis  of  the  nerve,  and 
near  the  eye,  the  outer  portion.  They  attribute  the  changes 
in  this  case,  however,  to  the  fact  that  the  patient  was  a 
smoker. 

Occasionally  retinal  changes  are  visible,  first  observed  by 
Ed.  Jager4  and  afterwards  by  Desmarres  and  Gralezowski. 
A  careful  study  of  them  has  been  made  by  Leber,5  by 
James  Anderson6  and  by  Nettleship7  (Fig.  74).  They  axe 
only  seen  when  the  disease  is  advanced.  In  such  cases  of 
diabetes,  albumen  is  often  present  in  the  urine  as  well  as 
sugar,  but  the  occurrence  of  these  retinal  changes  is  not 
related  to  the  albuminuria,  since  they  have  been  observed  in 
many  cases  in  which  not  a  trace  of  albumen  was  present. 

The  changes  in  the  retina  bear  considerable  resemblance 
to  those  of  albiiminuria,  and  still  greater  resemblance  to  those 
seen  in  some  cases  of  pernicious  anaemia.  Hiemorrhages 

1  'Centralbl.  fiir  prakt.  Augenheilk.,"  Feb.  1881,  p.  33. 

2  'Cent.  f.  prakt.  Augenh.,"  1882,  p.  202. 

3  'Trans.  Ophthalmological  Society,"  vol.  i.  p.  124. 

4  '  Beitrage  zur  Pathol.  des  Auges."    "\Vien,  1855,  taf.  xii. 

5  'Arch.  f.  Ophth.,"  xxi.  306. 

6  'Ophth.  Rev.,"  viii.  1. 

7  'Trans.  Ophth.  Soc.,"  vi.  331. 


DIABETES.  229 

are  conspicuous  in  many  of  the  cases,  but  may  be  entirely 
absent,  as  in  the  case  drawn  in  Fig.  74.  They  are  often 
situated  behind  the  vessels,  and  are  sometimes  of  considerable 
size.  They  may  exist  alone  or  may  lead  to  a  secondary 
parenchymatous  retinitis.  In  one  case,  figured  by  Jager, 
a  condition  of  parenchymatous  retinitis  existed  in  the 
posterior  segment  of  the  eyeball,  with  obscuration  of  the 
disc,  concealment  of  the  veins  in  places,  a  few  large  whitish 
spots,  and  a  few  striated  haemorrhages,  the  arteries  being 
unconcealed.  White  spots  of  degeneration  are  frequently 
present,  commonly  of  moderate  size,  scattered  over  the 
fundus.  They  are  situated  in  the  deeper  layers  of  the 
retina.  They  differ  from  the  patches  of  the  albuminuric 
retinitis  in  shape,  having  less  tendency  to  assume  a  circular 
form ;  in  colour,  having  a  more  dingy  shade  of  white ;  and 
in  grouping,  the  star  round  the  macula  being  seldom 
seen,  although  there  is  a  tendency  for  the  spots  to  be 
arranged  in  the  form  of  incomplete  rings.  Sometimes, 
however,  although  rarely,  there  may  be  a  perimacular  circle 
of  spots,  and  this  in  cases,  as  those  described  by  Noyes, 


FIG.  74. — OPHTHALMOSCOPIC  APPEARANCE  IN  A  CASE  OF 
RETINITIS  IN  DIABETES.     (Nettleship. ) 

The  disc  is  free  from  swelling.  Scattered  aboxit  the  fundus,  especially  in 
yellow  spot  region,  are  numerous  ill-defined  whitish  patches  (see  text). 
In  this  case  there  were  no  haemorrhages. 


230  MEDICAL   OPHTHALMOSCOPY. 

Desmarres,  Eales,  and  Culbertson,  in  which  there  is  no 
albumen  in  the  urine.  Occasionally  a  preponderant  papillitis 
may  be  present,  as  in  the  case  related  by  Culbertson,1  in 
which  consecutive  atrophy  resulted  and  caused  permanent 
amblyopia,  although  the  neuritis  was  apparently  cured. 
The  simple  atrophy  of  the  optic  nerve,  which  occasionally 
exists  alone,  may,  in  rare  cases,  accompany  the  retinal 
changes  (Gralezowski). 

A  marked  difference  from  the  forms  of  retinitis  which  it 
most  resembles  is  afforded  by  the  frequent  association,  in 
diabetes,  of  opacities  in  the  vitreous.  They  appear  to  be 
produced  by  the  escape  of  blood  in  small  quantities  from  the 
retinal  haemorrhages.  Leber  has  traced  the  development  of 
a  complete  opacity  of  the  vitreous  by  this  mechanism  of 
repeated  haemorrhagic  infiltration.  Occasionally,  hsemor- 
rhagic  glaucoma  is  the  result.  In  one  curious  case  recorded 
by  Nettleship2  there  were,  in  several  parts  of  the  fundus, 
capillary  loops,  apparently  from  the  choroid,  perforating 
the  retina,  and  projecting  for  several  millimetres  into  the 
vitreous.  In  another  case  he  found  by  the  ophthalmoscope 
numerous  small  dilatations  on  a  large  vein  near  the  disc.3 

Few  microscopical  examinations  have  been  made.  One 
by  Nettleship  is  recorded  by  S.  Mackenzie.4  The  chief 
change,  beyond  oedema,  was  a  peculiar  hyaloid  degenera- 
tion of  the  interna  of  the  arteries,  and  numerous  capillary 
aneurisms,  some  of  which  are  shown  in  Fig.  75.  These 
vascular  changes  afford  an  explanation  of  the  tendency  to 
haemorrhage.  In  this  case  the  vessels  of  the  brain  (and  of 
the  kidneys  and  spleen)  were  similarly  affected,  and  a  small 
cerebral  haemorrhage  had  occurred. 

Both  eyes  are  commonly  affected  in  diabetes.  The  dis- 
turbance of  sight  may  be  slight  or  considerable.  Blindness 
is  usually  the  result  of  the  extravasations,  or  of  secondary 
changes  in  the  vitreous.  In  Mackenzie's  case,  just  described, 

1  "Detroit  Lancet,"  April,  1880. 

2  "  Trans.  Ophth.  Soc.,"  vol.  viii.  p.  159. 

3  "Trans.  Ophth.  Soc.,"  vol.  viii.  p.  161. 

4  "Ophth.  Hosp.  Rep.,"ix.  p.  150. 


DIABETES. 


231 


the  disease  was  discovered  by  Waren  Tay  in  consequence 
of  the  result  of  the  ophthalmoscopic  examination.  There 
is  nothing  absolutely  pathognomonic  in  the  characters 
of  the  affection,  since  they  closely  resemble  the  albu- 
minuric  form.  In  addition  to  the  distinctions  already 
described,  the  most  suggestive  indications  are,  as  Leber 
points  out,  the  combination  of  the  retinal  change  with 
opacity  of  the  vitreous,  and  also  with  atrophy  of  the  optic 
nerve  having  the  characters  of  a  simple  atrophy.  In 
albuminuria,  atrophy  is  very  rare,  except  as  the  result  of 
neuritis. 

The  retinal  affection  is  apt  to  relapse,  even  though 
temporary  improvement  be  obtained  under  the  influence 
of  dietetic  treatment.  The  advanced  stage  of  the  disease 
at  which  it  occurs  also  renders  the  prognosis  unfavourable. 
The  treatment  is,  in  the  main,  that  for  the  general  disease. 
Carbolic  acid  is  suggested  by  Leber,  but  is  more  likely 
to  be  useful  in  the  diabetic  amblyopia,  without  retinal 
changes,  than  in  the  latter. 

In  very  rare  cases  optic  neuritis  and  glycosuria  may  both 
be  consequences  of  an  organic  cerebral  disease.  The  two 


TIG.  75.— CAPILLARY  ANEURISMS,  AND  VARICOSE  CAPILLARIES  FROM 
RETINA,  IN  A  CASE  OF  DIABETES  WITH  RETINAL  HEMORRHAGES. 

They  are  seen  in  the  course  of  the  vessels  (c)    at  their  bifurcation  (d),  and 
also  situated  laterally  (b).      (x    150.) 


232  MEDICAL   OPHTHALMOSCOPY. 

symptoms,  for  instance,  existed  in  a  case  recorded  by  Gross- 
mann,1  and  the  optic  neuritis  was  thought  to  be  due  to  the 
diabetes,  until  other  indications  of  a  cerebral  tumour  de- 
veloped. After  death  a  tumour  was  found  in  the  anterior 
part  of  the  base  of  the  brain,  and  the  fourth  ventricle  was 
distended  by  a  pseudo-membranous  mass. 

DIABETES  INSIPIDUS. — In  a  very  few  cases  of  diabetes 
insipidus,  ophthalmoscopic  changes  have  been  observed, 
which  have  not,  however,  much  analogy  with  those  observed 
in  diabetes  mellitus.  Atrophy  of  one  optic  nerve  was  observed 
by  Laycock,2  and  double  optic  neuritis  was  present  in  a  case 
described  by  Van  der  Heyden.3  The  connection  of  these 
changes  is  probably  with  the  cause,  rather  than  with  the 
condition,  of  polyuria.  It  must  also  be  remembered  that 
the  polyuria  of  contracted  kidney  is  sometimes  mistaken 
for  diabetes  insipidus. 


DISEASES    OF    THE    CIRCULATOEY    SYSTEM. 
DISEASES   OF   THE   HEART. 

The  veins  and  arteries  of  the  retina  participate  in  any 
general  changes  in  the  circulation  which  result  from  diseases 
of  the  valves  and  walls  of  the  heart,  although  the  changes 
in  them  are  commonly  less  marked  than  those  in  other 
vessels.  For  this  there  are  two  reasons — (1)  Their  size  is  far 
below  that  of  the  other  vessels  accessible  to  physical  exami- 
nation ;  (2)  the  conditions  of  the  intra-ocular.  tension  keep 
the  circulation  more  uniform  in  the  eye  than  in  other  parts. 

The  over-filling  of  the  venous  system,  from  over-distension 
and  dilatation  of  the  right  heart,  consequent  on  congenital 
disease  of  the  pulmonary  orifice,  on  emphysema,  and  other 
causes  of  pulmonary  obstruction,  and  on  disease  of  the 
mitral  orifice,  may  be  revealed  by  an  over-distension  of  the 
retinal  veins,  the  chief  trunks  being  large,  and  the  smaller 

1  "  Berl.  Klin.  Wochenschrift,"  1879,  p.  138. 
2  "  Lancet,"  1875,  ii.  242.  3  "  Leyden  Thesis,"  1875. 


DISEASES   OF   THE    HEART.  233 

veins  unduly  visible,  and  therefore  apparently  more  numerous. 
It  is  commonly  unattended  with  visual  disturbance,  although 
a  case  in  which  it  was  accompanied  with  transient  attacks  of 
amblyopia  has  been  described  by  Galezowski.  This  condition 
is  most  marked  in  congenital  cyanosis.  In  that  disease  the 
retinal  veins  may  be  enormously  dilated  (as  in  a  case  figured 
in  the  first  edition  of  Liebreich's  Atlas),  and  they  afford 
proof  of  the  degree  to  which  the  distension  of  the  venous 
radicles  contributes  to  the  cyanotic  tint.  Retinal  hsemor- 
rhages  occurred  shortly  before  death  in  a  case  of  congenital 
cyanosis  recorded  by  Stangloneier.1  In  acute  venous  over- 
distension,  such  as  occurs  during  effort,  during  severe  cough, 
or  during  an  epileptic  fit,  the  venous  congestion  may  also  be 
very  marked. 

Under-filling  of  the  arterial  system,  if  chronic,  such  a& 
occurs  in  aortic  obstruction  and  in  mitral  disease,  is  rarely 
evidenced  by  a  corresponding  state  of  the  retinal  vessels,  na 
doubt  on  account  of  the  second  local  influence  just  mentioned. 

Nor  is  chronic  over-action  of  the  left  ventricle,  if  sustained,, 
evidenced,  as  a  rule,  in  the  retinal  arteries,  probably  because 
the  cause  of  such  over-action  commonly  lies  between  these- 
minute  vessels  and  the  heart.  Exceptions  are,  however,, 
met  with.  In  exophthalmic  goitre,  in  which  the  over-action 
of  the  heart  depends  on  a  primary  nervous  disturbance,  and 
not  on  an  obstruction  to  be  overcome,  distension  (and  even 
pulsation)  of  the  arteries  may  be  visible.  The  former  is 
probably  in  part  due  to  dilatation  of  the  vessels  from  vaso- 
motor  paralysis.  (See  p.  198.) 

Sudden  over-action  of  the  heart,  as  from  emotion  or  violent 
exertion,  may  also  show  itself  in  visible  pulsation  of  the 
retinal  vessels  ;  rarely  in  the  arteries,  more  frequently  in  the- 
veins,  to  which  it  is  transmitted  from  the  arteries. 

In  aortic  regurgitation  pulsation  in  the  veins  is  common, 
and  pulsation  in  the  arteries  is  not  rare.  This  depends  on 
the  fact  that  the  force  of  the  pulse-wave  becomes  increased 
out  of  proportion  to  the  actual  movement  of  the  blood,  and 

1  "Inaug.  Dissert.  Wurzburg,  1878;  Nagel's  "Jahrbuch  fur  Ophth.," 
1878,  p.  261. 


234  MEDICAL   OPHTHALMOSCOPY. 

the  conditions  which  obtain  in  the  larger  arteries  pass  on, 
so  to  speak,  into  the  smaller  vessels,  and  even  overcome  the 
regulating  influences  of  the  eye  (see  p.  20).  In  one  case 
described,  the  existence  of  the  valvular  lesion  was  first 
suspected  from  this  pulsation. 

For  the  above-mentioned  reasons,  neither  simple  dilatation 
nor  simple  hypertrophy  of  the  left  side  of  the  heart  usually 
affects  the  size  of,  or  circulation  within,  the  retinal  vessels. 
Dilatation  only  acts  when  it  involves  the  right  side  of  the 
heart  in  an  extreme  degree,  and  then  may  cause  some  venous 
congestion.  But  hypertrophy,  when  its  cause  is  such  as  per- 
mits it  to  act  on  the  smaller  vessels,  may  produce,  although 
rarely,  retinal  haemorrhages.  It  is  doubtful  whether  it  is 
<3apable  of  doing  this  unless  rupture  be  permitted  by  vascular 
degeneration.  The  haemorrhages  which  result  may  lead  to 
degenerative  white  spots,  which  may  persist  after  the  dis- 
appearance of  the  effused  blood. 

Thrombosis  of  the  central  vein  occurs  in  rare  cases  of 
heart  disease,  mitral  and  aortic  (see  p.  30). 

Embolism  of  the  central  artery  of  the  retina  is  an  occasional 
consequence  of  valvular  disease  of  the  heart,  and  is  probably 
the  most  common  cause  of  amaurosis  associated  with  cardiac 
disease — a  coincidence  which  was  first  noted  by  Seidl  and 
Kanka  in  1846.1  Its  occurrence  is  governed  by  the  same 
conditions  as  those  which  determine  it  elsewhere.  It  is  most 
common  in  mitral  disease,  especially,  like  cerebral  embolism, 
in  mitral  constriction.  Its  signs  have  been  already  described 
<p.  33). 

Transient  failure  of  sight  without  ophthalmoscopic  changes 
is  common  in  heart  disease,  and  may  be  unilateral  and  con- 
siderable. To  the  latter  form  attention  has  been  lately  called 
by  Nettleship.2 

Malignant  Endocarditis. — In  the  rare  form  of  "  ulcerative 
endocarditis"  attended  with  fever  and  pyasmic  symptoms 
(which  Litten  better  designates  "  malignant  endocarditis  "), 
— the  "  diphtheritic  endocarditis  "  of  some  German  writers, 

1  Canstatt's  "  Jahresb.,"  1846,  iii.  115. 

2  "British  MedicalJournal,"  Jan.  14,  1879. 


DISEASES    OF    THE    VESSELS.  235 

due,  probably,  to  the  circulation  in  the  blood  of  organized 
elements  derived  from  some  septic   source — retinal  haemor- 
rhages are  almost  invariable,  and  of  considerable  diagnostic 
importance.       Choroidal1   and   even    conjunctival2   extrava- 
sations may  in  rare  cases  coexist.      Most  of  the  observed 
instances  have  occurred  after  childbirth,  and  they  are  de- 
scribed under  the  head  of  "  Septicaemia  "  (see  Fig.  82,  p.  295). 
Rosenbach,3  in  two  cases  in  which  ulcerative   endocarditis 
resulted  from  experimental  damage  to  the  valves  of  the  heart 
of  dogs,  found  retinal  haemorrhages,  minute,  in  streaks  and 
dots.     In  these  cases,  haemorrhagic  infarcts  with  abundant 
micrococci,  were  found  in  various  organs.      Hyperaemia  of 
the  papilla  was  associated  with  the  retinal  haemorrhages  in 
a  case  described  by  Michel.     In  the  optic  nerves  were  found, 
after  death,  many  dark  points,  due  to  capillary  embolism  and 
"miliary  abscesses."     Extravasations  into  the  kidney  were 
associated  with  bacterial  masses.     Virchow  has  described4  an 
interesting  case  of  panophthalmitis  (exudation  in  the  iris, 
vitreous,  retina,  and   choroid)   in   a   case   of  ulcerative  en- 
docarditis in  a  man,  and   he   found  minute  bodies  in  the 
damaged  spots,  which  would  probably  be  now  regarded  as 
micrococci.      He    also  proved  by   experiment  that  embolic 
obstruction  of  the  minute  vessels  caused  punctiform  extra- 
vasations in  the  retina.     In  a  case  of  ulcerative  endocarditis 
recently  recorded  by  J.  Hutchinson,  Jun.,  the  retina   was 
oedematous,  its  arteries  small,  and  it  showed  several  haemor- 
rhages.    All  these  changes  may  well  have  been  due  to  the 
presence  of  embolism,  but  other  facts  in  the  case  rendered  a 
different  explanation  of  the  ocular  condition  possible.5 

DISEASES  OF  THE  VESSELS. 

Chronic  changes  in  the  vessels  rarely  reveal  themselves  by 
retinal  signs.     Those  which  do  occur,  the  rare  coincidence  of 

1  Westphal  :  "  Arch  f.  Psychiatric,"  vol.  ix.  pt.  3,  p.  389. 

2  Michel :  "Arch.  f.  Ophth.,"  vol.  xxiii.  p.  113. 

3  "Arch,  fur  Exp.  Path.  u.  Therapie,"  1878. 

4  "Arch,  fur  Path.  Anat.,"  Bd.  x.  1856,  p.  179. 

5  "Trans.  Ophth.  Soc.,"  vol.  ix.  1889,  p.  152. 


236  MEDICAL   OPHTHALMOSCOPY. 

aneurisms  or  signs  of  degeneration  of  the  retinal  vessels, 
with  a  similar  change  elsewhere,  have  been  already  suffi- 
ciently considered  in  the  general  account  of  the  changes 
in  the  retinal  vessels. 

Nor  have  alterations  in  the  eye  been  observed  in  cases  of 
acute  lesions  of  the  vessels  elsewhere,  with  the  exception  of  a 
case  of  phlegmasia  dolens  recorded  by  Walter.1  The  sight 
of  one  eye  was  lost  four  days  after  parturition,  and  a  week 
before  the  onset  of  the  phlegmasia.  Some  weeks  later,  the 
retina  (then  first  examined)  showed  extreme  contraction  of 
the  retinal  vessels ;  the  optic  disc  was  pale  and  the  macula 
reddish.  The  appearances  were  supposed  to  be  due  to 
embolism.  The  retina,  however,  subsequently  became 
detached. 

DISEASES  OF  THE  BLOOD. 
PLETHORA. 

In  states  of  plethora  it  is  said  by  Jiiger  that  the  vessels 
are  large,  and  the  blood- column  dark.  The  changes  are 
not,  however,  sufficiently  well  marked  to  be  of  practical 
importance. 

ANAEMIA. 

ACUTE  ANEMIA  FROM  HAEMORRHAGE. — Loss  of  blood  is 
occasionally  followed  by  affection  of  vision,  and  the  loss  of 
sight  may  be  slight  or  complete,  transient  or  permanent,  and 
may  come  on  at  the  time  of  the  haemorrhage  or  not  until 
after  several  days. 

It  is  remarkable  that  sight  is  affected  much  more  fre- 
quently after  spontaneous  than  after  traumatic  haemorrhage, 
and  in  that  of  the  latter  form,  venesection  is  the  most  frequent 
antecedent,  accidental  or  surgical  wounds  being  very  rare 
causes.  This  may  be  related  to  the  circumstance  that  in 
traumatic  and  surgical  cases  the  health  is  less  frequently 

1  "  British  Medical  Journal,"  April  2,  1881. 


ANJEMTA.  237 

impaired  before  the  loss  of  blood  than  in  the  cases  in  which 
spontaneous  haemorrhage  occurs,  or  in  cases  in  which  vene- 
section is  performed.  I  am  not  aware  that  it  has  ever  been 
noted  in  cases  of  the  haemorrhagic  diathesis. 

For  a  valuable  compilation  of  the  statistics  of  these  cases 
we  are  indebted  to  Fries.1  Of  96  cases  in  which  the  form 
of  the  haemorrhage  was  noted,  in  34  (35  per  cent.)  the 
haemorrhage  was  from  the  gastro-intestinal  tract ;  in  24 
(25  per  cent.)  it  was  from  the  uterus,  in  most  cases  after 
childbirth,  in  a  few  from  menorrhagia ;  24  (25  per  cent.) 
were  due  to  the  artificial  abstraction  of  blood  (21  by  vene- 
section, 2  by  leeching,  1  by  cupping)  ;  in  7  cases  it  was 
due  to  epistaxis  ;  in  5  to  wounds ;  in  1  case  to  haemoptysis ; 
and  in  1  to  urethral  haemorrhage. 

The  loss  of  sight  commonly  follows  a  large  haemorrhage, 
and  especially  repeated  haemorrhages,  but  sometimes  occurs 
after  a  small  one.  Now  and  then  it  follows  immediately  on 
the  loss  of  blood  (in  26  per  cent,  of  the  cases) :  the  patient 
wakes  from  the  faint  to  find  himself  blind.  In  19  per  cent, 
it  occurs  during  the  first  twelve  hours  after  the  haemorrhage. 
More  frequently  an  interval  of  two  or  three  or  four  days 
occurs  between  the  two  events;  33  per  cent,  occur  after 
the  first  twelve  hours  and  before  the  eighteenth  day.  Fries 
found  that  the  prompt  onset  is  most  common  in  the  cases 
which  occur  after  venesection,  the  tardy  onset  after  spon- 
taneous haemorrhage.  Commonly  the  loss  of  sight  is  sudden ; 
rarely,  it  is  preceded  by  photopsy  and  pain  in  the  head  and 
back.  In  one  case  under  my  observation  neuralgic  pain 
above  the  eyes  occurred  after  the  (post-partum)  haemorrhage, 
and  lasted  for  several  days  after  the  onset  of  the  blindness. 
In  this  case  each  previous  confinement  had  been  followed  by 
a  similar  pain,  without  affection  of  sight.  Occasionally  the 
same  individual  has  suffered  from  transient  affection  of 
sight  after  haemorrhage  on  more  than  one  occasion,  as  in  a. 
case  recorded  by  Samelsohn,  in  which  temporary  blindness 
occurred  after  each  of  several  attacks  of  hsematemesis. 

1  "  Inaug.  Dissert.,"  Tubingen,  " Beilageheft  zu  den  Klin.  Monatsbl.  f. 
Augenheilk.,"  1876. 


238  MEDICAL    OPHTHALMOSCOPY. 

The  blindness  is  commonly  double  (in  90  per  cent. — Fries), 
rarely  one  eye  being  much  more  affected  than  the  other. 
In  10  per  cent,  of  the  cases  one  eye  is  affected  exclusively ; 
in  5  per  cent,  one  eye  becomes  blind  and  the  other  is  but 
slightly  affected.  The  loss  is  often  permanent  and  complete 
(in  65  per  cent.),  the  pupils  being  dilated  and  not  acting 
to  light.  Partial  or  complete  recovery  takes  place  in  about 
half  the  cases  (partial,  30  per  cent. ;  complete,  20  per  cent.). 
Leber1  thinks  the  loss  is  commonly  more  complete  when  the 
haemorrhage  is  from  the  stomach,  than  when  from  the 
intestines  or  uterus,  and  this  agrees  with  the  conclusions 
of  Fries,  that  improvement,  in  spontaneous  haemorrhage, 
is  most  common  after  haemorrhage  from  the  bowels.  Com- 
plete restoration  of  sight  has  been  observed  after  haemorrhage 
from  the  uterus,  from  the  intestines,  from  the  nose,  traumatic 
haemorrhage,  and  venesection ;  never  after  haemorrhage  from 
the  stomach.  Recovery  may  be  much  greater  in  degree 
in  one  eye  than  in  the  other.  It  may  be  complete  in 
both  eyes.  When  the  recovery  is  partial,  the  field  may  be 
limited,  but  the  limitation  varies  much  in  different  cases. 
In  the  case  after  childbirth,  above  mentioned,  although  the 
sight  of  both  eyes  was  lost  at  first,  the  right  recovered  with  a 
normal  field,  while  in  the  left  vision  was  only  ^,  and  the 
right  half  of  the  field  was  lost.  In  one  case  on  record,  the 
permanent  loss  was  in  the  lower  half  of  each  field,  and  was 
greater  in  the  left  than  in  the  right.  In  another  case 
(Uhthoff 2),  the  right  field  was  limited  above,  and  the  left 
field  was  limited  on  the  temporal  side,  while  the  nasal  half 
was  lost  except  in  two  small  islets.  The  colour-fields  were 
restricted  out  of  proportion  to  that  for  white.  In  a  case  of 
Samelsohn's,  in  one  eye  central,  in  the  other  peripheral, 
vision  was  left.  A  central  scotoma  was  also  observed  by 
Mandelstamm.3  Recurrent  transient  amaurosis  marked  one 
case  (Leber). 

The   ophthalmoscopic   appearances  some   time   after    the 

1  In  Graefe  u.  Saemisch's  "  Handbuch,"  vol.  v. 

2  "  Arch.  f.  Ophth.,"  vol.  xxvi.  pt.  1,  p.  274. 

3  "  Centralbl.  f.  prakt.  Augenh.  "  1879,  p.  175 


ANEMIA.  239- 

onset,  have,  in  rare  cases,  been  normal.  In  most  cases  the 
disc  is  atrophied  with  small  vessels,  as  in  the  case  I  have 
mentioned,  in  which  the  disc  was  greyish-white,  the  arteries 
much  narrowed,  the  veins  small  also,  and  much  new  tissue 
about  the  vessels  in  the  disc.  The  degree  of  narrowing  of 
the  vessels,  and  the  time  at  which  pallor  appears,  have  varied 
in  different  cases. 

In  the  few  ophthalmoscopic  examinations  which  have  been 
made  early  in  the  history  of  the  cases,  there  have  commonly 
been  signs  of  inflammation,  usually  slight,  sometimes  intense. 
The  slight  changes  consist  in  diffuse  opacity  of  the  retina 
with  some  oedema  of  the  disc,  the  more  intense  in  a  neuro- 
retinitis  with  haemorrhages.  The  larger  the  number  of  early 
observations  the  more  does  it  appear  that  the  permanent 
damage  to  sight  is  related  in  degree  to  the  intensity  of  the 
inflammation. 

In  one  case,  recorded  by  Hirschberg,1  three  days  after  the 
haemorrhage  there  was  slight  opacity  of  the  left  papilla ;. 
distinct  neuritis  in  the  other  eye  without  swelling ;  sight 
nearly  normal.  Five  days  later — R.,  intense  neuro-retinitis, 
V.  ^V ;  L.,  commencing  neuritis,  Y.  ^.  The  sight  of  the 
right  eye  was  lost  next  day.  Three  weeks  later — R.  disc  as 
in  neuritic  atrophy,  Y.  0  ;  L.  disc  merely  reddish  and  in- 
distinct, Y.  J.  Three  years  later  the  patient  died  of  cancer 
of  the  stomach :  the  fibres  of  the  optic  nerve  were  found  to 
be  replaced  by  nucleated  connective  tissue — there  was  no  evi- 
dence of  haemorrhage  into  the  nerve  sheath.  A  very  similar 
case  has  been  recorded  by  Landesberg.  The  day  after  a 
haemorrhage  from  the  nose,  dimness  of  sight  of  one  eye  was 
complained  of,  and  the  ophthalmoscope  showed,  in  both  eyes,, 
diffuse  opacity  of  the  retina  with  some  swelling  of  the  papilla. 
In  one  eye  the  appearances  soon  lessened,  and  sight  was 
normal ;  in  the  other  a  neuro-retinitis  with  haemorrhages 
developed,  with  ultimate  amaurosis.  Retinal  haemorrhages 
and  neuro-retinitis  were  observed  by  Woinow  after  the 
application  of  four  leeches  to  the  uterus.  In  a  case  published 

1  Hirschberg  :    "Kl.    Monatsbl.    f.    Augenheilk.,"    1877.      Supplement,. 
53-85. 


240  MEDICAL   OPHTHALMOSCOPY. 

by  Ulrich,1  the  changes  were  noted  a  few  minutes  after  an 
attack  of  haematemesis.  The  optic  discs  were  pale,  and  the 
vessels  on  its  surface  presented  a  normal  appearance.  At 
its  edge,  however,  the  veins  suddenly  lost  their  dark  red 
colour,  and  became  bright  red,  like  arteries.  There  were 
numerous  haemorrhages  and  white  spots  along  the  course 
of  the  vessels.  This  condition  of  the  veins  gradually 
disappeared,  and  in  two  months  the  fundi  and  vision  were 
normal.  The  same  observer  has  more  recently  recorded  three 
additional  cases  with  similar  ophthalmoscopic  appearances. - 

Forster  has  recorded  a  case,  in  which,  twelve  days  after 
a  haemorrhage,  there  was  a  peculiar  white  opacity  of  the 
retina,  with  small  haemorrhages  around  the  disc ;  vessels 
small,  but  not  as  in  embolism.  There  was  no  affection  of 
sight.  The  opacity  slowly  disappeared  without  neuritis.  So 
in  a  case  seen  by  Horstmann,  three  days  after  a  haemate- 
mesis,  disturbance  of  sight  occurred  (|)  with  slight  opacity 
of  the  optic  nerves  and  adjacent  retina.  The  changes 
gradually  lessened,  and  sight  became  normal.  On  the  other 
hand,  ten  days  after  loss  of  sight,  which  occurred  seven  days 
after  an  abortion,  Herter3  found  neuro-retinitis  with  haemor- 
rhages, quickly  subsiding  to  atrophy;  loss  of  sight  per- 
manent in  both  eyes.  Colsmann,  however,  four  days  after 
•onset,  found  only  pallor  of  disc,  small  arteries,  large  veins, 
and  no  neuritis. 

Many  theories  have  been  framed  to  account  for  the 
phenomena,  but  the  variety  in  the  changes  renders  the 
appearances  very  difficult  to  explain.  The  theory  which  has 
•obtained  most  acceptance  is  that  of  v.  Grraefe,  that  there  is 
a  retro-ocular  haemorrhage  situated  sometimes  near,  some- 
times far  from  the  eye.  The  evidence  in  favour  of  this 
theory  is  that  small  retinal  haemorrhages  have  been  seen,  that 
there  are  sometimes  haemorrhages  into  other  organs  in  cases 
of  loss  of  blood,  and  that  in  one  case  there  were  simultaneous 
.symptoms  of  a  cerebral  lesion.  But  this  affords  a  very 

1  "Klin.  Monatsbl.  f.  Augenh.,"  1883,  p.  183. 

2  "  Graefe's  Arch.  f.Ophth.,"  1887,  p.  1.    See"0phth.  Rev.,"  vol.  vii.  p.16. 

3  "Charite  Annalen,"  1887,  p.  525. 


ANJEMIA.  241 

inadequate  explanation  for  the  cases  in  which  both  eyes 
suffer.  Moreover  in  those  cases  which  have  been  examined 
post-mortem  there  has  been  no  evidence  of  such  haemorrhage. 
To  assume,  as  has  been  done,  that  the  mischief  is  at  the 
chiasma,  seems  unjustifiable,  in  the  entire  absence,  in  all 
such  cases,  of  other  symptoms  of  mischief  at  the  base  of  the 
brain.  Forster  attributed  the  slight  changes  in  his  case  to* 
serous  effusion.  Horstmann1  ascribes  the  symptoms  to  in- 
flammation in  the  optic  nerves.  Ulrich  regards  papillo- 
retinitis  found  after  great  loss  of  blood  as  due  to  disturb- 
ances in  circulation  in  the  papilla,  and  attributes  these 
latter  changes  to  the  establishment  of  an  abnormal  relation 
between  the  blood  and  the  vitreous-pressures.2  The  appear- 
ances noted  by  him  in  the  veins  immediately  after  severe 
haemorrhage  (see  p.  240)  he  adduces  as  a  proof  of  these 
circulatory  disturbances.  He  believes  that  there  is  always  a 
slight  hindrance  to  the  circulation  in  the  retinal  veins  where 
the  latter  bend  in  passing  over  the  edge  of  the  disc,  that  the 
influence  of  the  intra-ocular  pressure  is  to  increase  this  hin- 
drance, and  that  it  is  still  further  increased  by  the  occurrence 
of  any  reduction  in  the  blood-pressure.  Severe  loss  of  blood, 
then,  produces  a  condition  favourable  to  venous  stagnation 
by  reducing  the  blood-pressure  markedly,  while  the  intra- 
ocular pressure  is  not  affected  or  only  slightly  diminished. 
Samelsohn  thinks  that  the  nervous  connection  between  the 
stomach  and  the  corpora  quadrigemina  (lesions  of  which  are 
said  to  cause  gastric  haemorrhage)  affords  the  best  explanation,, 
while  von  Oettingen3  believes  that  he  has  proved  that  fatty 
degeneration  of  the  retinal  vessels,  quickly  following  the  loss 
of  blobd,  is  the  cause  of  the  extravasations  sometimes  seen. 

It  is  evident,  however,  that  in  the  majority  of  cases  there 
are  the  signs  of  inflammation,  and  there  is  at  present  no 
evidence  to  show  that  this  is  not  of  infra-ocular  origin.  It 
seems  probable  that  the  mechanism  may  vary  in  different 

1  "Kl.  Monatsbl.,"  1878,  p.  147. 

2  "Graefe's  Archiv,"  xxvi.  3,  p.  80. 

3  "Dorpat  Med.  Zeitschrift,"  1877,  Nos.  3  and  4,  and  Nagel's  "  Jahres- 
bericht,"  1877,  p.  239. 


242  MEDICAL    OPHTHALMOSCOPY. 

cases,  and  one  effect  of  loss  of  blood  may  be  upon  the  retinal 
elements  themselves.  The  shock  to  the  nervous  structures 
from  the  anaemia  may,  in  some  cases,  cause  transient  loss  of 
function,  of  sudden  or  slow  onset,  and  recovery  takes  place 
without  ophthalmoscopic  changes.  In  other  cases  no  recovery 
may  take  place,  and  atrophy  supervenes.  In  some  cases  the 
damage  to  the  nutrition  of  the  retina  may  lead  to  a  primary 
inflammation  on  the  restoration  of  the  blood-supply,  variable 
in  degree,  sometimes  slight  and  general,  sometimes  most 
intense  in  the  papilla,  where  inflammation  occasionally  occurs 
in  chlorosis. 

It  is  probable  that  more  light  will  be  thrown  on  the 
pathology  of  this  mysterious  accident  when  physicians  are 
more  generally  aware  of  the  ocular  symptoms  which  may 
accompany  haemorrhage,  and  use  the  ophthalmoscope  in  all 
cases  in  which  the  phenomena  are  likely  to  occur,  since  only 
too  many  of  such  cases  afford  opportunity  for  post-mortem 
investigation. 

SIMPLE  CHRONIC  ANJEMIA. — CHLOROSIS. 

The  colour  of  the  fundus  is  pale  in  proportion  to  the 
anaemia,  but  the  physiological  variations  in  the  tint  of  the 
choroid  and  of  the  disc  prevent  the  tint  of  the  fundus  from 
affording  any  absolute  indication.  In  extreme  cases  the 
•choroidal  pallor  may,  however,  be  striking,  as  it  was  in  a 
girl  with  chlorosis,  lately  under  my  care,  in  whom  the  red 
corpuscles  were  only  26  per  cent,  of  the  normal.' 

The  retinal  vessels  often  present  distinct  characters.  The 
veins  are  especially  pale,  often  only  a  little  darker  than 
the  arteries.  When  the  choroidal  pigment  is  abundant  it 
may  be  noted  that  its  influence  on  the  apparent  tint  of  the 
veins  is  greater  than  in  health ;  they  undergo  a  greater 
change  of  tint  in  passing  from  the  dark  choroid  on  to  the  pale 
•disc.  The  veins  are  also  often  broad,  probably  in  consequence 
of  the  defective  distension  and  consequent  flattening  in  their 
atonic  state  by  the  intra-ocular  pressure  (see  p.  10).  The 
reflection  from  them  varies,  commonly  being  broad,  no  doubt 


SIMPLE   CHRONIC   ANJEMIA CHLOROSIS.  243 

in  consequence  of  the  diminished  convexity.  The  arteries 
are  usually  narrower  than  normal,  not  merely  in  comparison 
with  the  veins,  but  absolutely ;  their  pallor  is  much  less 
noticeable  than  is  that  of  the  veins.  The  reflection  from 
them  may  also  be  broad.  Spontaneous  pulsation  in  the 
retinal  arteries  has  been  occasionally  observed  by  Becker1  in 
chlorotic  girls.  Schmall2  found  arterial  pulsation  in  20  out 
of  55  cases  of  chlorosis,  the  pulsation  being  usually  in  the 
form  of  locomotion  seen  at  the  bends  of  the  vessels. 
Haemorrhages  are  said  to  occur,  but  are  certainly  very  rare 
in  simple  anaemia,  and  probably  only  take  place  where  there 
is  a  great  absolute  deficiency  in  the  number  of  red  corpuscles. 
I  have,  however,  found  them  absent  in  a  case  in  which  the 
corpuscles  were  only  26  per  cent,  of  the  normal. 

A  valuable  paper  on  the  changes  found  in  the  f undus  oculi 
in  anaemia,  based  on  the  examination  of  fifty  cases,  has  been 
published  by  Saundby  and  Bales.3  They  did  not  observe 
arterial  pulsation  in  any  of  the  cases,  and  venous  pulsation 
not  more  frequently  than  in  healthy  individuals.  In  five 
of  the  cases  (10  per  cent.)  there  was  slight  blurring  of  the 
disc,  mostly  with  hypermetropia,  and  in  four  there  were 
whitish  or  yellowish  patches  of  exudation  near  the  disc,  or 
.scattered  at  the  periphery.  In  one  case  there  were  two 
haemorrhages  near  the  disc ;  and  in  several  there  were 
small  white  spots,  or  small  spots  of  pigment,  presumably 
left  by  haemorrhages. 

Neuritis  occasionally  occurs  in  chlorotic  girls.  Two 
undoubted  instances  have  been  recorded  by  me,4  and  one  of 
these  is  figured  at  PL  VII.  5.  In  each  case  the  anaemia 
was  very  great,  the  haemoglobin  being  reduced,  out  of  pro- 
portion to  the  corpuscles,  in  one  to  30,  and  in  the  other 
to  38  per  cent.  The  first  case  suffered  from  a  relapse  of 
neuritis  on  a  recurrence  of  anaemia.  In  each  case  the  im- 
provement was  most  rapid  under  the  influence  of  iron. 

1  "Klin.  Monatsbl.,"  Jan.  1880,  p.  1. 

2  "  Graefe's  Archiv,"  xxxiv.  i.,  p.  37  ;  "  Ophth.  Rev.,"  1888,  p.  268. 

3  "Ophth.  Rev.,"i.  303. 

4  "Brit.  Med.  Journ.,"  1881,  i.  793. 


244  MEDICAL    OPHTHALMOSCOPY. 

The  degree  of  neuritis  was  slight  in  the  first  case,  but  very- 
considerable  in  the  second.  In  the  case  figured  in  PL 
VIIT.  1  and  2,  the  neuritis  must,  I  think,  be  ascribed  to 
the  same  cause.  The  patient  was  watched  for  two  years 
after  the  subsidence  of  the  neuritis,  and,  except  for  an 
occasional  headache,  there  was  never  the  slightest  other 
symptom  to  suggest  intra-cranial  disease.  I  have  never 
known  neuritis  from  cerebral  disease  to  develope  with  the 
extreme  rapidity  exhibited  by  this  case ;  and  such  intensity 
of  progress,  in  conjunction  with  the  entire  absence  of 
cerebral  symptoms,  excludes,  I  think,  an  intra-cranial 
cause.  Iodide  of  potassium  was  first  given,  but  no  im- 
provement occurred  until  iron  was  substituted,  too  late, 
unfortunately,  to  prevent  partial  atrophy.  I  fear  that  the 
permanent  damage  to  sight  was  in  part  due  to  the  delay 
in  the  administration  of  iron.  Another  case  of  intense 
neuro-retinitis  with  haemorrhages  in  a  chlorotic  girl  i& 
recorded  by  Mr.  E.  Williams.1  Rapid  recovery  took  place  on 
the  administration  of  iron. 

It  is  worthy  of  note  that  all  the  patients  presented  a 
slight  degree  of  hypennetropia.  It  is  generally  admitted 
that  this  condition  is  capable  of  causing  slight  congestion 
of  the  disc,  and  if  so,  it  is  possible  that,  in  these  cases  of 
chlorotic  neuritis,  the  hypermetropia  may  help  in  setting 
up  the  changes  in  the  papilla  which,  in  the  special  blood- 
state,  progress  to  a  much  more  intense  degree  than  they 
would  otherwise  attain. 

Hirschberg  first  noted  the  occurrence  of  optic  neuritis  in 
chlorosis,  and  an  instance,  in  a  girl  of  sixteen,  quickly 
cured  by  the  administration  of  iron,  has  been  recorded 
by  Bitsch.2 

PROGRESSIVE  PERNICIOUS  ANAEMIA. 

In  pernicious  anaemia  the  tint  of  the  fundus  and  the 
appearance  of  the  arteries  and  veins  are  such  as  are  seen 
in  the  most  intense  cases  of  simple  anaemia.  The  rather 

1  "Brit.  Med.  Journ.,"  1884,  i.  10. 

2  "  Klin.  Monatsbl.,"  April,  1879,  p,  144. 


PROGRESS^E    PERNICIOUS    ANAEMIA.  245 

narrow  arteries  and  broad  pale  veins  are  seen  in  PL  XI.  1, 
from  a  case  which  has  been  published  by  Stephen  Mac- 
kenzie.1 The  figure  shows  also  that  which  is  a  characteristic 
feature  in  pernicious  anaemia,  the  tendency  to  haemorrhage. 
Common  in  other  situations,  it  is  far  more  frequent  in  the 
retina  than  elsewhere.  Of  sixteen  cases  examined  by  Uuincke, 
retinal  haemorrhages  were  absent  in  one  only.  In  thirty 
cases  examined  by  Homer,  extravasations  were  present 
"  almost  without  exception."  The  extravasations  are  often, 
as  in  the  figure,  numerous,  and  more  or  less  striated  or 
flame-shaped,  from  their  situation  in  the  layer  of  nerve- 
fibres.  They  are  usually  most  abundant  around  the  optic 
nerve  entrance.  They  are  frequently  associated  with  white 
spots  and  areas,  due  in  part  to  leucocyte-like  cells,  in  part 
to  degeneration  in  the  disturbed  retinal  tissues,  varicose 
enlargement  of  the  nerve- fibres,  giving  rise  to  finely 
granular,  spherical,  and  fusiform  bodies.  Homogeneous 
•("  colloid  ")  and  finely  granular  masses  have  also  been  found 
in  the  inter-granule  layer.2  Occasionally  a  pale  spot  may 
occupy  the  centre  of  a  small  haemorrhage.  In  such  a  case 
Manz3  found  the  pale  centre  to  consist  of  round  colourless 
cells,  sometimes  enclosed  in  a  capsule.  He  found  also  ampul- 
lifonn  and  sacculated  dilatations  of  the  capillaries  (no  doubt 
similar  to  those  seen  in  Fig.  75,  from  a  case  of  diabetes). 
Some  of  these  were  empty,  others  contained  a  granular 
material,  others  contained  red  blood  corpuscles  or  colourless 
cells.  He  supposes  that  the  capsule  found  to  enclose 
the  pale  cells  within  the  haemorrhages  was  really  the  wall 
of  such  a  capillary  dilatation.  A  stellate  arrangement  of 
white  specks  around  the  macula  lutea  was  seen  by  Uuincke 
in  one  case,  but  is  certainly  rare  in  this  disease.  (Edema 
of  the  retina  was  also  observed  in  one  case  by  Quincke, 
the  vessels  being  dimmed  by  a  bluish-white  cloud.  The 
optic  disc  is  usually  normal,  but  its  edges  may  be  blurred, 
and  optic  neuritis  may,  in  rare  cases,  be  present  in  excess 

1  "  Lancet,"  Dec.  7,  1878. 

2  Uhthoff :  "Klin.  Monatsbl.,"  Dec.  1880. 

3  "Centralbl.  fur  d.  Med.  Wiss.,"  1875,  p.  675. 


246  MEDICAL    OPHTHALMOSCOPY. 

of  the  other  retinal  changes,  as  in  the  case  of  a  boy  described 
by  Stephen  Mackenzie.1 

The  haemorrhages  are  in  many  cases  quickly  absorbed, 
lasting  only  a  few  weeks.  They  cause  no  disturbance  of 
vision  except  when  located  in  or  near  the  macula  lutea.  It 
is  probable  that  when  the  actual  diminution  of  the  blood 
corpuscles  is  ascertained  in  these  cases,  a  relation  may  be 
traced  between  a  certain  degree  of  diminution  and  the  occur- 
rence of  these  haemorrhages.  In  one  case  the  hcemorrhages 
appeared  when  the  corpuscles  fell  to  27  per  cent,  of  the 
normal,  and  increased  with  the  progressive  fall  of  the  cor- 
puscles, which  before  death  were  only  12  per  cent.,  and  the 
haemoglobin  8  or  9  per  cent,  of  the  normal.2 

Scorbutic  Ancemia. — A  form  of  anaemia  which  may  be  thus 
distinguished,  appears  to  be  a  distinct  variety  of  pernicious 
anaemia.  It  is  characterized  by  the  same  progressive  pallor 
and  systemic  effects  of  the  deficiency  of  blood  corpuscles,  but 
differs  in  the  occurrence  of  an  affection  of  the  gums  resem- 
bling that  met  with  in  scurvy,  and  in  extravasations  into  the 
skin.  There  may  also  be  other  cutaneous  rashes,  such  as  are 
met  with  in  cachectic  conditions.  Haemorrhages  may  occur 
into  the  retina  just  as  in  the  ordinary  form  of  pernicious 
anaemia.  It  appears  not  to  be  in  any  degree  due  to  deficiency 
in  vegetable  food,  but  to  be  occasionally  produced  by  absti- 
nence from  meat. 

An  example  of  this  form  was  described  to  the  Ophthal- 
mological  Society  by  Dr.  Stephen  Mackenzie.3  The  patient 
was  a  lad,  aged  eighteen,  who  had  had  syphilis,  but  no  cause 
for  the  blood-disease  could  be  traced.  The  symptoms  were 
swelling  of  the  gums,  enlargement  of  the  glands  beneath  the 
jaw,  petechial  haemorrhages  in  the  skin,  haemorrhage  from  the 
gums,  and  profound  anaemia.  Vomiting  preceded  death.  In 
the  retina  were  abundant  fusiform  haemorrhages,  gradually 
increasing  in  number  until  there  were  twenty  or  thirty  in 
each  retina,  some  as  large  as  the  papilla.  Ultimately  general 

1  "  Lancet,"  Dec.  7,  1878. 

2  S.  Mackenzie  :  "Trans.  Ophth.  Soc.,"  vol.  i.  p.  48. 

3  Ibid.,  p.  51. 


LEUCOCYTHJEMIA.  247 

retinal  oedema  occurred.  The  corpuscular  richness  of  the 
blood  gradually  decreased,  during  two  months  the  patient 
was  under  observation,  from  51  to  13  per  cent,  of  the 
normal.  The  coloured  corpuscles  varied  in  size,  some  pre- 
senting fissures  or  cracks.  The  colourless  corpuscles  were 
not  in  excess,  except  to  a  slight  degree  towards  the  close. 
They  were  small  and  spherical.  The  haemoglobin  was 
reduced  out  of  proportion  to  the  corpuscles.  No  treatment, 
dietetic  or  medicinal,  appeared  to  influence  the  course  of  the 
disease.  After  death,  haemorrhages  were  found  in  the  lungs 
and  on  the  surface  of  the  heart. 

In  a  case  of  my  own,  the  symptoms  were  very  similar  to 
those  of  Dr.  Mackenzie's  case.  There  were  the  same  pro- 
gressive anaemia,  swelling  of  the  gums,  cutaneous  and  retinal 
extravasations,  and  haemorrhages  found  after  death  in  the 
lungs  and  heart.  In  this  case,  however,  the  patient  had  for 
a  long  time  abstained  almost  entirely  from  animal  food, 
taking  plenty  of  vegetables.  There  were  also,  in  addition  to 
and  accompanying  the  extravasations,  papules  with  infiltra- 
tion of  the  adjacent  skin.  After  death  a  peculiar  change 
was  found  in  the  periosteum  of  some  of  the  bones. 

I  lately  saw,  with  Mr.  Grellet,  of  Hitchin,  a  woman,  aged 
thirty-seven,  who  presented  very  similar  symptoms,  except 
that  there  were  no  retinal  haemorrhages.  The  affection  in  this 
case  also  came  on  after  entire  abstinence  from  animal  food 
for  several  weeks,  vegetable  food  being  freely  taken.  There 
were  extreme  anaemia,  swollen  spongy  gums,  cutaneous 
petechiae,  and  small  erythematous  spots  on  the  limbs,  with  a 
papule  in  the  centre,  which  became  vesicular  and  formed  a 
scab.  Under  large  doses  of  iron  she  had  begun  to  improve, 
and  Mr.  Grellet  has  since  informed  me  that  the  symptoms 
passed  entirely  away. 

LEUCOCYTHJEMIA. 

In  all  cases  of  leucocythaemia  in  which  the  change  in  the 
blood  is  considerable,  the  retinal  and  choroidal  vessels  are 
remarkably  pale.  The  tint  of  the  choroid  is  usually  an 


248  MEDICAL   OPHTHALMOSCOPY. 

orange-yellow,  but  if  there  be  much  choroidal  pigment  the 
tint  may  be  little  changed.1  The  retinal  veins  appear  broad 
and  very  pale.  This  apparent  increase  in  width  is  sometimes 
very  great  (Fig.  76),  and  is  probably  due  to  atony  and  flat- 
tening rather  than  to  passive  distension.  They  are  often  very 
tortuous.  Their  central  reflection  may  at  first  be  broad  and 
indistinct ;  ultimately,  in  the  large  tortuous  vessels,  a  very 
narrow,  almost  white,  reflection  appears.  The  retinal  arteries 
are  orange  rather  than  red,  and  in  extreme  cases  they  are 
small. 

Besides  these  appearances,  there  are,  in  a  considerable 
number  of  cases,  actual  changes  in  the  retina.  These  vary 
greatly  in  different  cases,  and  rarely  present  the  appearance 
described  by  their  discoverer,  Liebreich,  as  "  leukaemic 
retinitis."  They  are  almost  confined  to  the  splenic  variety, 
and  are  usually  double,  one  eye  being  often  more  affected 
than  the  other. 


FIG.  76. — BROAD  RETINAL  VEINS  AND  NARROW  ARTERIES. 

From  a  case  of  leucocythwrnia. 
1  Leber  :  "  Graefe  and  Saemisch's  Handbuch, "  vol.  v.  p.  600. 


LEUCOCYTH^EMIA.  249 

The  commonest  change  is  the  occurrence  of  retinal  haemor- 
rhages. The  tendency  to  haemorrhage  in  this  disease  is 
extremely  strong,  and  leads  to  extravasations  into  the  retina 
in  a  large  number  of  cases.  Statistics  which  I  have  collected1 
show  that  the  most  common  recorded  seat  of  extravasation 
into  tissues  is  the  subcutaneous  cellular  tissue.  A  more  con- 
stant use  of  the  ophthalmoscope  will  probably  show  that  retinal 
haemorrhage  is  as  frequent,  if  not  more  so.  Of  five  cases 
of  leucocythaemia  which  I  have  examined  with  the  ophthal- 
moscope, retinal  extravasations  were  visible  at  some  period  in 
four.  Of  the  tendency  to  haemorrhage  these  extravasations 
constitute  a  striking  indication.  The  tendency  to  retinal 
haemorrhage  is  apparently  far  greater  in  leucocythsemia  than 
in  simple  anaemia,  for  it  occurs  with  a  percentage  of  red 
corpuscles  greater  than  is  usual  in  cases  of  simple  anaemia 
which  present  retinal  haemorrhages.  I  have  twice  met  with 
them  in  leucocythaemia  when  the  blood  contained  50  per  cent, 
of  red  corpuscles.  One  of  these  cases  is  figured  in  PL  XI. 
Fig.  2.  The  haemorrhage  encircles  the  fovea  centralis  in  a 
curious  series  of  extravasations,  and  several  smaller  ones  lie 
adjacent.  Commonly  the  haemorrhages  are  more  widely 
scattered,  and  more  or  less  striated.  The  haemorrhages 
are  in  these  cases  usually  in  the  nerve-fibre  layer,  but  a 
large  extravasation  may  infiltrate  the  whole  thickness  of 
the  retina.  When  the  excess  of  white  corpuscles  is  con- 
siderable, the  effused  blood  has  a  pale,  chocolate  tint  here 
as  in  other  situations.  Extravasation  may  take  place  into 
the  substance  of  the  papilla,  or  haemorrhage  may  occur 
into  the  vitreous.2 

Besides  the  haemorrhages,  white  or  yellowish  spots  are 
commonly  present,  often  most  abundant,  in  the  periphery,  or 
near  the  macula  lutea.  These  are  sometimes  irregular,  but 
often  rounded,  and  edged  by  a  halo  of  extravasation.  When 
large,  they  are  sometimes  distinctly  prominent,  and  may  be 
as  much  as  2  mm.  in  diameter  (Eeincke).  They  consist 
•commonly  of  leucocytes,  similar  to  the  leucocytes  of  the 

1  Art.  Leucocythsemia,  "Reynolds'  System  of  Medicine,"  vol.  v.  p.  257. 

2  Vide  Perrin  and  Poncet's  "Atlas,"  pi.  65. 


250  MEDICAL    OPHTHALMOSCOPY. 

blood,  and  they  have  been  regarded  as  lymphoid  growths 
such  as  occur  in  other  organs.  In  rare  cases,  actual  growths 
of  some  size  have  been  met  with,  but  it  is  doubtful  whether 
the  smaller  spots  are  of  this  nature.  It  is  common  for 
the  pale  corpuscles  to  be  aggregated  in  the  middle  of  an 
extravasation.  In  some  cases  the  white  spots  are  due  to 
degeneration  of  the  retinal  elements.  The  capillaries  are 
full  of  white  corpuscles,  and  it  seems  more  probable  that 
these  spots  arise  by  the  escape  of  the  corpuscles  by  diapedesis 
or  by  rupture.  In  one  case  Saeniisch  found  an  irregular 
thickening  of  the  inner  granule  layer,  in  some  places  extend- 
ing into  the  ganglion-cell  layer.  He  attributes  the  thicken- 
ing to  escaped  leucocytes,  which  are  indistinguishable  from 
the  corpuscles  of  the  granule  layer.  Poncet  has  found  a 
similar  infiltration  extending,  not  only  into  all  the  layers 
of  the  retina,  but  also  into  the  substance  of  the  optic  nerve. 
Swelling  of  the  nerve-fibre,s  was  the  cause  of  small  white 
spots  in  a  case  described  by  Deutschmann.1  The  capillaries 
of  the  retina  may  be  dilated  and  varicose,  such  as  are  shown 
(from  a  case  of  diabetes)  in  Fig.  75.2  The  lymphatic 
sheaths  of  the  vessels  may  be  filled  with  white  blood 
corpuscles. 

Occasionally  a  diffuse  opacity  of  the  retina  is  met  with, 
said  by  Roth  to  be  due  to  a  thickening  of  the  vertical  fibres 
of  the  retina,  but  probably  sometimes  due  to  oedema — of  the 
ganglion-cell  layer  in  the  case  described  by  Deutschmann,1 
of  both  ganglion-cell  and  nerve-fibre  layers  in  a  case  examined 
by  Oeller,3  in  which  both  these  layers  were  twice  the  normal 
thickness.  When  considerable  it  is  in  part  due  to  a  diffuse 
infiltration  of  leucocytes,  as  described  by  Poncet  and  Oeller. 
This  opacity,  with  some  swelling  and  great  tortuosity  of  the 
veins,  was  the  chief  appearance  in  one  case  under  my  own 
observation.  The  patient  was  a  woman,  aged  thirty-six,. 
in  University  College  Hospital,  under  the  care  of  Dr. 
Wilson  Fox.  Both  eyes  were  affected  in  a  similar  manner. 

1  "Kl.  Monatsbl.  fur  Augenheilk.,"  1887,  p.  231. 

2  Such  capillaries  are  figured  by  Poncet,  "  Atlas,"  pi.  66. 

3  "Arch.  f.  Ophth.,"  xxiv.  1878,  pt.  iii.  241. 


LEUCOCYTH^EMIA.  251 

The  discs  were  clear,  the  sclerotic  ring  distinct,  and  the 
physiological  cup  quite  normal.  The  tint  of  the  periphery 
of  the  disc  was  rather  deep,  but  there  was  no  punctiform 
redness.  There  was  a  diffuse,  slight  opacity  of  the  retina, 
chiefly  marked  near  the  disc  and  somewhat  striated  on  direct 
examination.  Towards  the  periphery  of  the  retina,  a  few 
small  white  spots  were  seen,  and  one  small  haemorrhage. 
The  arteries  were  nearly  normal  in  size,  but  unduly  tortuous. 
The  veins  were  greatly  increased  in  diameter,  and  much 
paler  than  natural.  Their  central  reflection  was  everywhere 
distinct  and  broad.  The  smaller  veins  were  conspicuous  and 
could  be  followed  for  a  longer  distance  than  normal.  The 
larger  veins  were  very  tortuous,  the  curves  being  chiefly 
in  the  plane  of  the  retina,  but  some  antero-posterior.  One 
or  two  small  veins  on  leaving  the  disc  were  lost  in  the 
opacity  of  the  retina,  but  the  larger  veins  were  not  concealed. 

A  remarkable  change  was  observed  by  Heinzel, l  in  a  case 
of  lymphatico-splenic  leucocythsemia  in  a  child,  4J  years  of 
age.  There  was  at  first  an  enormous  swelling  of  both 
papillse,  which  were  occupied  by  a  striated  opacity,  com- 
pletely concealing  the  disc,  without  redness,  ceasing  two 
discs'  breadth  from  the  edge.  The  retina  presented  here  and 
there  a  little  opacity.  There  was  moderate  tortuosity  of  the 
veins,  and  the  vessels  were  bordered  by  pale  lines  of  variable 
width.  Xumerous  haemorrhages  appeared  and  disappeared 
in  each  retina.  All  the  pathological  appearances  passed  away 
in  four  weeks,  the  fundus  appearing  normal  but  pale,  and  it 
was  also  found  normal  after  death.  Heinzel  remarks  that 
the  appearance  had  not  the  aspect  of  an  inflammatory  process, 
but  rather  that  of  mechanical  congestion  with  consequent 
cedema  and  ecchymoses.  Such  a  condition  was  presented  in 
the  same  case  by  the  conjunctiva,  and  several  times  by  the 
skin,  and  was  ascribed  to  the  constitutional  state.2 

In    cases   of   general  thickening  of  the  retina,  the  optic 

1  "  Jahrbuch  flir  Kinderheilk.,"  1875,  p.  346. 

2  The  ophthalmoscopic  appearances  may  have  been  due  to  thrombosis  in 
the  orbital  vein,  the   anastomoses  with  the  facial   ultimately  sufficing  to 
restore   the  normal   circulation.      Venous  thrombosis   is  common  in    this, 
disease. 


252  MEDICAL   OPHTHALMOSCOPY. 

papilla  has  been  found  swollen  (to  '9  mm. — Oeller)  in 
consequence  of  leucocytal  infiltration  and  oedema.  The 
leucocytes  were  densely  massed  in  front  of  the  lamina  cribrosa. 
The  disc  is  not  usually  changed,  however,  except  when  the 
parenchymatous  retinal  changes  are  considerable. 

The  haemorrhages  may  be,  in  some  cases  of  leucocythsemia, 
so  numerous  as  to  give  to  the  changes  the  aspect  of  a 
haemorrhagic  retinitis,  such  as  is  met  with  occasionally  in 
other  conditions.  A  large  extravasation  may  burst  through 
into  the  vitreous,  and  cause  secondary  glaucoma.  The 
vessels  are  sometimes  accompanied  with  conspicuous  white 
lines. 

Besides  the  changes  which  appear  related  to  the  blood- 
state,  the  complication  of  kidney  disease  may  lead  to  retinal 
changes,  identical  in  appearance  and  structure  with  those  met 
with  in  cases  of  primary  renal  disease,  as  in  a  case  figured  by 
Poncet.1 

The  degree  to  which  the  changes  interfere  with  sight 
depends  on  their  extent  and  position.  If  abundant  they 
cause  considerable  amblyopia ;  if  slight  the  vision  may  be 
unimpaired,  and  the  retinal  changes  may  easily  be  over- 
looked, unless  systematic  examination  is  made  with  the  oph- 
thalmoscope. In  a  case  recorded  by  Hirschberg2  the  patient 
sought  advice  in  consequence  of  seeing  a  red  balloon  con- 
stantly before  his  right  eye,  and  the  ophthalmoscope  showed 
a  large  haemorrhage  of  corresponding  shape  in  the  macular 
region,  with  numerous  small  ones  scattered  over  the  fundus. 
His  blood  and  spleen  were  examined,  and  the  diagnosis 
of  leucocythaemia  confirmed.  A  month  later,  an  exactly 
similar  haemorrhage  occurred  in  the  left  eye,  giving  rise  to  a 
spectral  red  balloon  in  that  eye  also.  When  situated  near 
the  macula,  central  vision  is  much  impaired;  in  the  case 
figured,  for  instance  (PI.  XII.  2),  it  was  very  dim,  but  not 
lost.  Occasionally  the  disturbance  of  the  retinal  elements 
leads  to  a  curious  change  in  vision,  as  in  one  case  in  which 
parallel  lines  appeared  to  come  near  together,  and  again  to 

1  Perrin  and  Poncet:  "Atlas,"  pi.  66. 

2  "Centr.  f.  prakt.  Augenh.,"  1887,  p.  97  ;  "Ophth.  Rev.,"  1888,  p.  12. 


PURPURA.  253 

diverge.  Double  exophthalmos,  from  a  lymphoid  growth  in 
both  orbits,  was  present  in  a  remarkable  case  of  leucocythsemia 
described  by  Leber.1  Ketinal  haemorrhages  were  also  present. 
A  case  of  exophthalmos  in  this  disease,  described  by  Chauvel,2 
was  probably  of  the  same  nature. 

Sometimes  the  choroid  is  found  infiltrated  with  leucocyte- 
like  cells,  and  its  vessels  may  be,  at  the  same  time,  greatly 
dilated.  From  these  two  changes,  in  Oeller's  case,  the 
choroid,  near  the  outer  side  of  the  disc,  was  swollen  to  eight 
times  the  normal  thickness.  It  was  difficult  to  say  whether 
the  leucocytes  were  free  or  were  contained  in  the  enormously 
dilated  vessels.  Poncet  has  figured  an  infiltration  of  the 
iris  with  leucocytes,  supposed  to  indicate  a  leucocythaemic 
iritis. 

PURPURA. 

The  tendency  to  rupture  of  vessels  in  purpura  leads  to 
retinal  as  well  as  to  subcutaneous  extravasation.  How 
frequently  retinal  haemorrhages  occur  cannot  be  ascertained 
until  the  ophthalmoscope  is  more  generally  used  by  physi- 
cians, but  they  are  certainly  very  common,  perhaps  invariable 
in  the  severer  forms  of  the  affection.  Cases  have  been 
recorded  by  Euc,3  Stephen  Mackenzie,4  and  others.  In 
each  of  two  fatal  cases  recently  under  the  care  of  Dr.  Hunt, 
late  of  "Wolverhampton,  retinal  haemorrhages  were  present 
and  numerous.5  The  extravasations  are  for  the  most  part 
striated,  and  adjacent  to  vessels,  and  most  abundant  in  the 
neighbourhood  of  the  optic  disc.  In  a  case  recorded  by 
Groodhart,6  a  large  subretinal  extravasation  was  present,  and 
was  thought  to  be  in  the  choroid.  It  had  a  white  edge,  and 
white  spots  have  been  seen  in  connection  with  the  retinal 
haemorrhages  in  this  as  in  other  affections.  The  occurrence 

1  "Arch.  f.  Ophth.,"  vol.  xxiv.  1878,  p.  295. 

2  "Gaz.  Hebd.,"1877,  No.  23. 

3  "I/Union  Med.,"  1870. 

4  "Med.  Times  and  Gaz.,"  1877   292. 

5  Oral  communication. 

6  "Lancet,"  1878,  i.  p.  123. 


254  MEDICAL   OPHTHALMOSCOPY. 

of  extravasations  into  the  retina  indicates  a  severe,  but 
not  necessarily  fatal,  degree  of  the  disease.  The  haemor- 
rhages may  disappear,  and  be  replaced  by  others,  and  the 
patient  may  ultimately  recover.  Haemorrhage  into  the 
choroid  was  also  found  post-mortem  by  Rue,  in  a  case  in 
which  a  large  number  of  retinal  extravasations  were  observed 
•during  life.  The  latter  may  cause  considerable  amblyopia 
if  numerous,  and,  as  in  other  cases,  if  near  the  macula  lutea, 
may  damage  central  vision. 

SCURVY. 

Retinal  haemorrhages  have  been  found  in  scurvy,  but  less 
commonly  than  in  purpura  ;  perhaps  because  they  have  not 
been  looked  for.  They  are,  as  in  purpura,  commonly  in  the 
neighbourhood  of  the  optic  nerve.  In  one  case  recorded  by 
Wegscheider,1  numerous  small  extravasations  into  the  brain 
co-existed. 

DISEASES   OF  THE  LUNGS. 

Pulmonary  affections  rarely  cause  ocular  troubles.  Em- 
physema of  the  lungs  may  lead  to  mechanical  congestion 
of  the  venous  system  generally,  which  may  be  conspicuous 
in  the  eye.  The  same  influence  has  been  ascribed,  but  on 
very  doubtful  grounds,  to  phthisis,  in  which  amblyopia 
occasionally  occurs.  Schmall  mentions  that  he  has  often 
seen  a  more  or  less  lively  injection  of  the  fundus  in  this 
disease,  and  that  he  found  visible  arterial  pulsation  in  five 
cases.2  Tubercles  in  the  choroid  may  be  met  with  in  cases 
of  acute  tuberculosis,  but  never  when  the  tubercular  affection 
is  confined  to  the  lungs.  Acute  pneumonia  is  said,  in  one 
case,  to  have  been  associated  with  neuro-retinitis.  A  febrile 
intense  bronchial  catarrh  in  a  young  woman,  with  much 
cyanosis,  was  observed  by  Litten3  to  be  accompanied  with 

1  "  Deutsche  Med.  Wochenschr.,"  Nos.  17  and  13,  1877. 

a  "Graefe's  Archiv.,"  xxxiv.  i.  p.  37  ;  "  Ophth.  Rev.,"  1888,  p.  268. 

1  "Charite  Annalen  "  for  1876.     Berlin,  1878. 


DISEASES   OF   THE    DIGESTIVE    ORGANS.  255 

neuro-retinitis,  in  and  around  the  papilla,  of  gradual  develop- 
ment, and  with  numerous  extravasations,  some  with  white 
centres,  near  the  equator  of  the  eye.  Many  of  the  extrava- 
sations were  regularly  arranged,  and  situated  upon  small 
veins ;  and  he  suggests  that  the  changes  were  probably  set 
up  by  the  great  distension  of  the  veins.  The  retinal  affec- 
tion subsided  with  the  bronchitis. 


DISEASES  OF  THE  DIQESTIYE  OBGANS. 

The  occasional  effect  of  haemorrhage  from  the  stomach  and 
intestine  has  been  already  described.  Gralezowski l  associates 
atrophy  of  the  optic  nerve,  in  some  cases,  with  chronic 
gastric  troubles.  He  has  described  several  remarkable  cases 
in  which  great  improvement  occurred  in  amblyopia,  pre- 
viously obstinate,  on  correcting  gastric  or  intestinal  troubles. 
In  some  cases  there  was  also  tenderness  of  the  lower  cervical 
spine.  Chronic  diarrhoea  may  also,  in  the  opinion  of  the 
same  author,  lead  to  a  "  peri  vascular  retinitis,"  in  which 
an  infiltration  of  the  retina,  causing  opacity,  may  extend 
around  the  vessels.  The  association  of  these  conditions 
has  not,  however,  been  generally  recognized. 

Constipation  is  regarded  by  Eales2  as  having  been  in- 
fluential in  causing  retinal  haemorrhage  in  a  series  of  cases 
observed  by  him.  All  were  young  men,  with  slow  pulse  and 
high  arterial  tension,  and  two  had  a  slight  trace  of  albumen 
in  the  urine.  The  extravasations  were  chiefly  in  the  left 
retina,  roundish  in  form  as  if  in  the  deeper  layers.  He 
speculates  that  the  constipation  may  have  been  due  to  or 
accompanied  by  vaso-motor  spasm  in  the  abdominal  vessels, 
sufficient  to  cause  a  general  increase  of  arterial  tension. 

Jaundice. — The  changes  in  the  blood  from  jaundice,  from 
any  cause,  may  occasion  retinal  haemorrhage.3  Jager  says 

1  "Journ.    d'Ophthalmologie,"  March,   1872.       "  L'Union  Med.,"  1876, 
i.  p.  368. 

2  "  Birmingham  Medical  Review,"  July,  1880,  p.  262. 

3  Litten  :  "  Zeitsch.  f.  Klin.  Med.,"  v.  i.  p.  319. 


256  MEDICAL    OPHTHALMOSCOPY. 

that  the  blood  in  the  vessels  may  have  a  yellowish  tint,  but 
the  appearance  is  probably  due  to  a  tint  in  the  media,  such 
as  in  rare  cases  causes  yellow  vision. 


DISEASES  OF  THE  SEXUAL  OBGANS. 

Sexual  excess  in  men  has  been  said  to  cause  atrophy  of  the 
optic  nerve,  but  the  evidence  in  support  of  the  relation  of 
the  two  is  not  strong. 

Sudden  suppression  of  the  menses  has  been  observed  to  be 
followed  by  acute  optic  neuritis,  such  as  accompanies  menin- 
gitis, and  often  attended  with  unpleasant  sensations  in  the 
head.  The  occurrence  of  the  neuritis  is  probably  analogous 
to  the  occasional  production  of  other  acute  changes  in  the 
nervous  system,  such  as  acute  myelitis,  from  the  same  cause. 

In  chronic  menstrual  irregularities,  optic  neuritis,  of  chronic 
course,  has  been  found,  and  occasionally  other  disturbances, 
such  as  retinal  haemorrhages.  It  is  probable  that  in  most 
cases  of  this  character  the  two  conditions — the  ocular  and 
menstrual  disturbance — are  related  to  a  common  cause.  In  a 
case  recorded  by  Spencer  Watson  retinal  haemorrhages  with 
high  arterial  tension  occurred  at  the  climacteric  period  (see 
p.  28). 

The  occurrence  of  loss  of  sight,  sometimes  with  neuritis, 
after  uterine  hsemorrhage  has  been  already  mentioned  (p.  237). 

In  pregnancy,  albuminuric  retinitis  is  occasionally  de- 
veloped. Under  the  title  "amaurosis  by  reflex  irrita- 
tion," Landesberg1  has  related  two  remarkable  cases  of 
amblyopia,  with  limitation  of  field,  coming  on  in  pregnancy. 
In  one  case  the  affection  of  sight  quickly  passed  away ;  in 
the  other  it  was  accompanied  by  hemiansesthesia,  and  cyclitis 
developed,  which  necessitated  enucleation.  A  similar  con- 
dition has  been  observed,  apparently  due  to  menorrhagia. 
The  nature  of  these  cases  is  obscure.  Although  most  cases 
of  affection  of  sight  from  pregnancy  are  produced  through 
the  agency  of  albuminuric  retinitis,  it  would  seem  that 
1  "Arch.  f.  Ophth.,"  xxiv.  pt.  1,  p.  161. 


TUBERCULOSIS.  257 

more  direct  influence  is  sometimes  exerted.  Loring1  has 
described  a  case  in  which  each  of  three  pregnancies  was 
accompanied  with  failure  of  sight,  the  first  two  in  the  outer 
half  of  one  field,  the  last  in  the  outer  half  of  each,  with 
general  impairment  of  vision. 


DISEASES   OF  THE  SKIN. 

It  has  been  said  by  some,  especially  by  Mooren,  that 
general  skin  diseases  may  be  accompanied  by  inflammation 
of  the  retina  and  papilla ;  that  eczema  of  the  head  may  be 
accompanied  by  optic  neuritis,  ending  in  atrophy.  The 
statement  has,  however,  received  no  confirmation,  and  the 
relation  of  the  two  conditions  must  be  considered  as 
exceedingly  doubtful.  If  such  a  sequence  occurs,  it  is 
possibly  by  the  production  of  a  local  orbital  cellulitis.  The 
suppression  of  a  customary  cutaneous  discharge,  such  as 
that  of  eczema,  has  also  been  said  to  cause  neuritis,  but  the 
statement  needs  corroboration. 

A  case  of  slow  atrophy  of  both  optic  nerves,  associated 
with  a  general  herpetic  eruption  on  the  skin,  diagnosed  by 
Hebra  as  "  chronic  herpes  zoster,"  has  been  recorded  by 
Hubsch.2  But  the  patient  passed  through  a  condition  of 
delirium  to  one  of  imbecility,  and  the  atrophy  was  probably 
part  of  a  widely  spread  degeneration  of  the  nervous  system,, 
of  which  the  skin  eruption  may  have  been  an  effect. 


CHEONIC  GKENEKAL  DISEASES. 
TUBERCULOSIS. 

The  grey  granulations  which  constitute  the  anatomical 
lesion  in  tuberculosis  may  form  in  the  vascular  structures  of 
the  eye,  chiefly  in  the  choroid,  rarely  in  the  iris  and  retina. 

1  "  New  York  Med.  Jour.,"  1883,  p.  59. 

2  "Ann.  d'Oculist,"  1872,  p.  239. 


258  MEDICAL    OPHTHALMOSCOPY. 

When  present  in  the  fundus,  they  may  readily  be  seen  with 
the  ophthalmoscope.1 

Tubercles  in  the  choroid  (Fig.  77)  appear  to  the  ophthal- 
moscope as  white,  yellowish-white,  or  reddish-yellow  spots, 
usually  isolated,  and  more  or  less  rounded  in  form. 
They  are  palest  in  the  centre,  and  commonly  redder  on 
their  outer  portions,  and  the  peripheral  redness  passes 
gradually  into  that  of  the  adjacent  choroid.  They  com- 
monly develope  in  the  substance  of  the  choroid,  and  the 
pigment  and  vessels  atrophy  before  the  growing  nodule, 
first,  and  more  completely,  at  the  centre,  so  that  the 
diameter  of  the  tubercle  on  section  may  be  found  to  be 
twice  or  three  times  as  great  as  that  of  its  exposed  portion 
(Fig.  78).  In  size  they  vary  from  one-third  of  a  millimetre, 
to  two,  or  two  and  a  half  millimetres,  i.e.,  from  about  one- 
fourth  to  half  or  three-quarters  the  diameter  of  the  optic 
disc.  The  larger  sizes  are  rare.  Occasionally  several  are 
aggregated  together  to  form  a  mass  which  may  be  the  size 
of  the  disc  or  even  larger — seven  or  eight  millimetres  in 


FIG.  77. 

FIGS.  77 — 79. — TUBERCLES  OF  THE  CHOROID  FROM  A  CASE  OF  ACUTE 
MILIARY  TUBERCULOSIS  IN  A  CHILD. 

FIG.  77. — The  front  of  the  eye  has  been  removed,  and  the  retina  is  drawn 
over  to  the  left.  Six  tubercles  are  seen,  varying  in  diameter  from  1  to 
4  mm.  (  x  2).  They  are  prominent  in  the  darker  periphery,  the  pigment- 
epithelium  over  the  choroid  is  intact,  and  where  it  has  disappeared  the 
tubercle  appears  within. 

1  That  tubercles  occurred  in  the  choroid  as  a  post-mortem  observation  has 
long  been  known.  They  were  described  by  Autenrieth  in  1808.  They  were 
first  observed  with  the  ophthalmoscope  by  Ed.  Jager  in  1855. 


TUBERCULOSIS. 


259 


diameter.  These  larger  masses  project  considerably  into 
the  eye.  Slight  prominence  may  commonly  be  recognized 
in  all  the  larger  tubercles,  and  assists  the  diagnosis.  The 
smaller  ones  may  resemble  spots  of  choroidal  exudation  or 
atrophy.  From  the  former,  their  rounded  shape  and  yel- 
lowish tint  distinguish  them.  From  atrophy,  the  tint, 
regular  form,  concealment  of  the  choroidal  vessels,  and  the 
(common)  absence  of  any  adjacent  pigmentary  disturbance 
are  sufficient  distinctions.  They  are  plainly  behind  the 
retinal  vessels.  In  structure  they  consist  of  the  same  lym- 
phoid  cells  as  constitute  the  granulations  elsewhere.  The 
cells  are  distinct  in  the  periphery,  degenerated  in  the  centre 
(Fig.  79).  Extravasations  of  blood  existed  in  the  substance 
of  a  granulation  in  one  case  examined  by  myself.  The 
tubercles  are  situated  chiefly  at  the  middle  of  the  fundus, 


FIG.  78. 

FIG.  78. — Section  of  two  of  the  smaller  of  these  tubercles.  They  occupy 
the  whole  thickness  of  the  vascular  layer,  pushing  forward  the  pigment- 
epithelium,  and,  in  the  case  of  the  right  hand  one,  breaking  through  it. 
(x  30.) 


FIG.  79. 

FIG.  79. — One  half  of  a  tubercle,  which  has  caseated.  Above  it,  in  the  centre, 
where  it  has  a  granular  aspect,  the  pigment-epithelium  has  disappeared 
towards  the  centre,  and  below  are  the  deeper  pigment  cells  of  the  choroid. 
(x  100.) 


260  MEDICAL    OPHTHALMOSCOPY. 

not  far  from  the  optic  nerve  entrance.  Usually  only  three  or 
four  are  present ;  sometimes,  however,  as  many  as  twelve  or 
twenty  or  even  fifty  (Cohnheim).  They  may  form  rapidly, 
and,  according  to  Strieker,  may  become  recognizable  in  from 
twelve  to  twenty-four  hours.  But  it  must  be  remembered 
that  they  attain  a  considerable  size,  without  disturbance  of 
the  epithelium,  and  the  partial  removal  of  this  may  rapidly 
increase  their  distinctness. 

The  tubercles  begin  as  minute  points,  "  masses  of  lym- 
phoid  cells,"  and  develope  in  the  structure  of  the  choroid, 
advancing  towards  the  retina  until  they  cause  atrophy  of 
the  pigmentary  layer  over  the  choroid,  and  become  ophthal- 
moscopically  visible.  When  the  tubercles  are  large  and  grow 
rapidly,  the  pigment  frequently  remains  on  their  surface  in 
the  form  of  spots. 

Choroidal  tubercles  occur  in  both  children  and  adults, 
and  in  the  chronic  as  well  as  in  the  acute  forms  of  tuber- 
culosis, but  are  most  frequent  in  the  acute  forms.  They 
are  practically  confined  to  the  cases  in  which  tubercle  is 
widely  distributed.  Their  actual  frequency  in  these  cases 
cannot  yet  be  stated.  It  is  evident,  from  the  rapidity 
of  their  appearance,  that  repeated  ophthalmoscopic  exami- 
nation is  necessary  to  exclude  their  occurrence.  Cohnheim 
described  them  as  very  commonly  to  be  found  after  death, 
and  Litten  found  them  (post-mortem)  in  thirty-nine  out 
of  fifty-two  cases.  According  to  most  observers  they  are 
much  less  frequently  to  be  seen  during  life  than  these 
figures  would  suggest.  In  this  country,  at  any  rate,  they 
appear  to  be  comparatively  rare.  As  a  rule,  when  they 
are  discovered,  it  is  not  until  the  disease  has  become 
advanced.  Exceptions  to  this  have,  however,  been  recorded, 
as  in  one  case  in  which  they  were  present  before  fever  or 
other  symptoms  of  the  disease  were  developed.1  StefPen,2 
again,  found  them,  in  one  instance,  six  weeks  before  the 
commencement  of  tubercular  meningitis.  In  such  a  case 

^raenkel:  "Bed.  Kl.  Wochenschr.,"  1872;  "  Jahrbuch  fur  Kinder- 
heilk.,"  Bd.  ii. 

2  "Jahrbuch  fur  Kinderheilk.,"  1870. 


TUBERCULOSIS.  261 

they  may  afford  great  assistance  to  diagnosis.  Their  pre- 
sence, then,  is  of  value  as  evidence  of  general  tuberculosis, 
especially  in  cases  in  which  the  diagnosis  of  acute  tuberculosis 
from  other  acute  febrile  conditions  is  difficult ;  their  absence 
is  of  no  significance.  Tubercles  of  the  choroid  often 
coincide  with  tubercular  meningitis,  but  in  a  few  cases  they 
have  been  met  with  when  the  membranes  were  free  from 
tubercle.  It  is  remarkable  that  the  characteristic  bacilli 
cannot  be  found  in  many  cases,  although  they  have  been 
readily  detected  in  the  tubercles  of  the  membranes  in  the 
same  subjects.  Thus  out  of  six  cases  examined  by  Lawford, 
they  could  not  be  detected  in  four,  after  the  most  thorough 
investigation  in  various  ways,  while  in  the  other  two  he 
found  them  with  ease.1  Haab,  however,  found  them  almost 
invariably.2  In  a  case  of  choroidal  tubercle,  where  bacilli 
could  not  be  demonstrated,  the  inoculation  of  a  guinea-pig 
with  the  crushed  tubercle  pro'duced  general  tuberculosis.3 

As  a  rule  choroidal  tubercles  cause  no  symptoms.  Tran- 
sient disturbances  in  sight  have,  however,  been  described. 
In  a  case  related  by  Manz4  tubercular  growths  perforated  the 
sclerotic  and  appeared  on  the  exterior  of  the  eye. 

Occasionally,  although  rarely,  a  tubercular  mass  developes 
in  the  deeper  structures  of  the  eye,  quite  similar  to  the 
masses  of  the  same  nature  which  are  found  in  the  brain. 
One  case,  in  which  such  growths  were  associated  in  these  two 
situations,  has  come  under  my  observation ;  optic  neuritis 
was  also  present.  A  tubercular  mass,  with  granulations  in 
the  neighbourhood,  infiltrated  the  greater  part  of  one  optic 
nerve  and  invaded  the  eye,  in  a  case  described  by  Chiari,5 
appearing  as  a  white  prominence  in  the  position  of  the 
papilla,  five  disc -diameters  in  width. 


1  "  Trans.  Ophth.  Soc.,"  vi.    p.  348,    where  a  summary   of  the    results 
obtained  by  various  observers  will  be  found.  • 

2  "  Klin.  Monatsbl.  fur  Augen.,"  1884,  p.  391. 

3  Alexander:   "  Centralb.  f.  Augenh.,"  1884,  p.  161. 

4  "  Klin.  Monatsbl.,"  Jan.  1881,  p.  26. 

•'"Wien.  Med.  Jahrbuch,"  1877,  p.  559.     Sattler :   "Arch.   f.  Ophth.,' 
Bd.  xxiv.  pt.  iii.  p.  127. 


262  MEDICAL    OPHTHALMOSCOPY. 

Choroidal  tubercles  were  found  by  Cohnheim  in  a  guinea- 
pig  rendered  tubercular  by  inoculation. 

Retina. — The  occurrence  of  tubercles  of  the  retina  has 
been  recorded  in  very  rare  instances.  The  aggregations  of 
lymphoid  cells  which  may  occur  in  the  nuclear  and  mole- 
cular layers,  adjacent  to  an  inflamed  disc  in  tubercular 
meningitis,  have  been  regarded  as  such,  but  their  tuber- 
cular nature  is  uncertain.  Unequivocal  tubercles  in  the 
retina  (often  containing  giant  cells)  have  usually  been 
associated  with  tubercular  growths  in  almost  all  the  struc- 
tures of  the  eye  (Perls,  Manfredi),  in  rare  cases  with  a 
tubercular  papillitis  only  (Weiss,  Sattler).  In  the  case  of 
tubercle  of  the  optic  nerve  referred  to  above,  the  optic 
papilla  was  the  seat  of  a  large  mass  of  caseating  tubercle, 
and  miliary  tubercles  were  scattered  through  all  the  layers 
of  the  adjacent  retina.1 

Tubercles  in  the  eye  are,  as  already  stated,  almost  invari- 
ably part  of  general  tuberculosis.  In  one  case,  however, 
they  were  found  in  all  parts  of  the  eye,  although  absent 
elsewhere.2 

Local  deposits  of  tubercle  in  the  encephalon  may,  as 
already  described,  give  rise  to  ophthalmoscopic  changes, 
producing  optic  neuritis,  as  do  other  cerebral  tumours.  In 
rare  instances  tubercular  masses  are  situated  in  the  intra- 
cranial  portion  of  the  optic  nerves3  or  in  the  chiasma,4  and 
may  cause  a  corresponding  affection  of  sight  (probably  with 
or  without  evidence  of  descending  neuritis).  The  inflam- 
mation which  accompanies  the  formation  of  tubercle  in  the 
meninges  may  also  be  accompanied  by  neuritic  changes  in 
the  eye  (see  p.  173). 

In  tuberculosis  of  the  brain  of  guinea-pigs,  artificially 
produced,  Deutschmann5  has  found  a  development  of  tuber- 
cles in  the  sheaths  of  the  optic  nerves  close  to  the  eye, 
accompanied,  during  life,  by  slight  papillitis.  The  disease 

1  "Arch.  f.  Ophth.,"  xxiv.  pt.  iii.  p.  150. 

-  Weiss  :  "Arch.  f.  Ophth.,"  xxiii.  pt.  iv.  p.  57. 

3  Cruveilhier :  "Anat.  Path.  Gen.,"  1862,  Bd.  iv. 

4  Hjort :  "El.  Monatsbl.,"  1867,  p.  166. 

5  "  Arch.  f.  Ophth.,"  xxvii.  pt.  i.  p.  251. 


MORBID    GROWTHS — SYPHILIS:  263 

appeared  to  have  resulted,  not  by  direct  continuity  with 
that  in  the  brain,  but  by  the  passage  of  a  materies  morbi 
into  the  sheath,  and  its  arrest  at  the  anterior  extremity  of 
the  vaginal  space.  Changes  at  the  same  spot,  apparently 
tubercular,  and  accompanied  by  a  perineuritis  and  some 
interstitial  neuritis,  were  found  in  a  child  who  had  died 
of  tubercular  meningitis.1  The  changes  ceased  a  centimetre 
from  the  eye.  There  were  no  ophthalmoscopic  changes. 

Tubercular  disease  of  the  lungs  has  been  described  by 
some  observers  as  accompanied  by  mechanical  congestion  of 
the  retinal  veins  and  by  disturbed  vision,  but  it  is  very 
doubtful  whether  these  are  in  any  cases  related  to  the 
pulmonary  affection. 

MORBID  GROWTHS. 

Morbid  growths  other  than  tubercular  are  very  seldom 
present  at  the  same  time  in  the  eye  and  brain.  Cancer 
of  both  choroids  has,  however,  been  observed  by  Puts, 
occurring  secondarily  to  a  primary  epitholioma  of  the 
lung. 

SYPHILIS. 

ACQUIRED  SYPHILIS. — The  syphilitic  diseases  of  the  eye, 
during  their  active  stage,  commonly  come  under  the  care  of 
the  ophthalmic  surgeon .  Their  consequences  in  the  fundus 
oculi  are,  however,  among  the  appearances  which  the 
physician  encounters  most  frequently  in  his  own  work, 
and  which  often  furnish  him  with  very  useful  informa- 
tion. A  knowledge  of  these  changes  is,  therefore,  of  great 
importance. 

Iris. — Although  not  strictly  an  ophthalmoscopic  sign,  the 
evidence  of  a  past  attack  of  iritis  is  often  first  discovered  by 
the  ophthalmoscope  revealing  the  presence  of  uveal  pigment 
on  the  anterior  surface  of  the  lens.  In  the  majority  of  cases 
iritis  is  due  to,  and  its  traces  are  signs  of,  constitutional 

1  "  Virch.  Arch.,"  Ivi.  p.  497. 


264  MEDICAL    OPHTHALMOSCOPY. 

syphilis ;  and  the  importance  of  the  evidence  thus  afforded, 
from  its  frequency  and  easy  recognition,  can  hardly  be  over- 
rated. Over  and  over  again  it  must  have  occurred  to  all 
physicians  who  use  the  ophthalmoscope,  when  looking  for 
changes  in  the  fundus  oculi,  to  encounter  these  signs  of  past 
iritis,  in  cases  in  which  syphilis  had  not  been  suspected, 
and  often  in  which  no  other  indication  of  it,  in  history  or 
symptoms,  was  to  be  obtained. 

Choroid. — Next  to  the  iris,  the  choroid  is  affected  by 
syphilitic  disease  more  frequently  than  any  other  part  of 
the  eye.  In  spite  of  the  opinions  which  have  been  expressed 
by  some  authorities,  there  is  strong  reason  to  believe  that 
disseminated  choroiditis  is,  in  the  great  majority  of  cases, 
syphilitic.  In  its  active  stage,  in  which  extensive  areas  of 
white  exudation,  comparable,  in  Hutchinson's  opinion,  to 
gummata,  are  the  conspicuous  features,  it  rarely  comes  under 
the  notice  of  the  physician.  In  its  later  stage,  in  which 
extensive  regions  of  atrophy  alternate  with  scattered  stellate 
and  crater-like  pigmentary  deposits,  and  sometimes  with 
haemorrhages,  it  is  often  met  with.  It  is  to  be  remembered 
that  the  pigment  is  deposited  in  the  retina  as  well,  and 
care  must  be  taken  to  avoid  confounding  the  change  with 
primary  retinitis  pigmentosa.  The  choroiditis  of  acquired 
syphilis  may  be  either  unilateral  or  bilateral.  When  slight, 
the  traces  of  it  may  be  detected  only  in  the  peripheral  part 
of  the  retina  towards  the  ora  serrata. 

Retina. —  Isolated  syphilitic  retinitis  is  less  common  than 
syphilitic  choroiditis.  It  is  characterized  by  areas  of  diffuse 
opacity,  parenchymatous  swelling,  tortuous  vessels,  and  a 
blurred  disc.  The  vitreous  frequently  shows  fine  dust-like 
opacities.  Sight  is  considerably  impaired.  This  form  also 
comes  chiefly  under  the  ophthalmic  surgeon's  notice. 

Optic  Nerve. — Neuritis,  limited  to  the  papilla,  is  common 
in  syphilis,  as  secondary  to  brain  disease,  but  is  very  rare  as 
a  primary  syphilitic  affection,  if  it  ever  occurs.  (See  pp. 
151,  152.)  Neuritis  has,  however,  been  met  with  secondary 
to  a  syphiloma  of  the  trunk  of  the  optic  nerve. 

Simple  atrophy  of  the  nerve  is  said  occasionally  to  occur, 


SYPHILIS.  265 

as  the  consequence  of  syphilis,  double,  unaccompanied  by 
spinal  symptoms  (Gralezowski).1  The  occurrence  of  atrophy 
from  this  cause  is  not  surprising,  since  there  is  reason  to 
believe  that  constitutional  syphilis  is  a  powerful  predisponent 
to  locomotor  ataxy,  in  its  purely  degenerative  form.  It  is 
probable  that  one-half  the  patients  with  ataxy  would  not 
suffer  from  the  disease  had  they  not  at  some  previous  time 
suffered  from  syphilis.2  This  is  true  of  cases  with,  as  well  as 
of  those  without,  optic  nerve  atrophy.  Moreover,  the  loss  of 
reflex  action  of  the  iris,  which  so  commonly  accompanies 
ataxy,  may  occur  without  spinal  symptoms  in  cases  of  con- 
stitutional syphilis,  as  in  several  cases  which  I  have  seen. 
One  of  them  presented  also  optic  nerve  atrophy,  similar  to 
that  which  accompanies  spinal  disease ;  but  of  such  disease 
there  were  no  symptoms  ;  even  the  knee-jerk  was  normal. 

INHERITED  SYPHILIS. — The  characteristic  indication  of 
inherited  syphilis  which  is  afforded  by  interstitial  inflam- 
mation of  the  cornea,  and  a  knowledge  of  which  we  owe  to 
Mr.  Hutchinson,  is  well  known,  and  does  not  come  within 
the  scope  of  the  present  work. 

Of  the  deeper  structures  of  the  eye,  the  one  most  liable  to 
be  affected  is  the  choroid,  which  is  often  the  seat  of  dissemi- 
nated inflammation,  in  infancy  or  later.  Scattered  areas  of 
atrophy  may  be  left,  associated  with  accumulations  of  pig- 
ment, just  as  in  the  form  which  results  from  the  acquired 
disease.  When  slight,  small  round  spots  of  atrophy  may  be 
seen,  surrounded  with  pigment.  This  form  is  very  charac- 
teristic, although  rare,  and,  when  the  pigment  is  slight, 
is  sometimes,  as  I  have  seen,  mistaken  for  tubercles  of  the 
choroid.  The  course  of  the  choroiditis  is  well  illustrated  by 
two  cases  described  by  T.  Barlow,3  in  one  of  which  the 
autopsy  showed  also  chronic  syphilitic  disease  of  the  cerebral 

1  "  Journ.  d'Ophthalmologie,"  March,  1872,  p.  139. 

2  For  the  evidence  on  which  this  statement  is  made,  see  "Syphilis  and 
Locomotor  Ataxy,"   "  Lancet,"  Jan.  1881,  p.  94,  and  the  statistics  of  Erb 
there  referred  to,   and  also  those  brought  by  him  before  the  International 
Medical  Congress,  1881. 

3  "Trans.  Path.  Soc.,"  1877,  p.  287. 


266  MEDICAL    OPHTHALMOSCOPY. 

membranes.  The  choroid  presented,  in  each  case,  brownish 
flecks  of  exudation  without  disturbance  of  pigment  or 
atrophy.  The  microscopical  examination  (by  Nettleship) 
showed  the  chorio-capillaris  beneath  these  flecks  to  be  infil- 
trated with  pus-like  cells,  and  in  several  instances  there  was 
a  layer  of  flattened  cells  on  the  surface  next  to  the  retina. 
In  the  other  case  Barlow  traced  the  progress  of  similar  flecks 
to  a  stage  of  atrophy,  such  as  is  seen  in  disseminated 
choroiditis — the  condition  occasionally  met  with  later  on  in 
life.  Several  cases  of  this  character  have  been  recorded  by 
Hutchinson.1 

A  peculiar  form  of  atrophy  of  the  disc  has  several  times 
come  under  my  notice  in  children  the  subjects  of  this  disease. 
The  disc  has  a  uniform  reddish  tint,  the  edges  are  not  well 
defined,  and  the  vessels  are  small.  There  has  not  commonly 
been  any  atrophy  of  the  choroid  or  pigmentary  accumulation. 
It  is  probably  secondary  to  retinitis  or  widespread  capillary 
choroiditis.  Several  times  since  first  observing  the  connection 
between  the  two  conditions,  this  form  of  atrophy  has  drawn 
my  attention  to  the  existence  of  inherited  syphilis,  which  had 
otherwise  escaped  notice.  Sight  is  usually  impaired,  some- 
times considerably. 

Ketinitis  sometimes  occurs  in  the  inherited  just  as  in  the 
acquired  disease. 

Retiriitis  pigmentosa  is,  by  some,  believed  to  be  connected 
with  inherited  syphilis,  and  an  instance  of  the  association  of 
the  two  diseases  has  been  described  by  Swanzy.  Deposits  of 
pigment  in  the  retina  occasionally  accompany  the  atrophic 
changes  in  disseminated  choroiditis,  but  the  connection  of 
true  retinitis  pigmentosa  with  syphilis  is  generally  considered 
to  be  very  doubtful. 

1  One  is  figured  in  the  "  Ophth.  Hosp.  Rep.,"  vii.  PI.  4,  Fig.  3.  Mr. 
Hutchinson  has  suggested  that  the  condition  of  choroidal  atrophy  and 
choroidal  and  retinal  pigmentation  may  occur  without  an  exudative  stage. 


GOUT.  26? 


CHRONIC  RHEUMATISM. 

Chronic  rheumatism  has  only  accidental  associations  with 
changes  in  the  fundus  oculi.  Neuro-retinitis  has  been 
ascribed  to  "  rheumatism."  Probably  some  of  the  cases  were 
instances  of  gout,  with  albuminuric  retiiiitis  due  to  granular 
kidneys.  It  must  be  remembered  also  that  the  optic  nerve, 
like  the  other  orbital  nerves,  may  be  damaged  by  rheumatic 
inflammation  at  the  back  of  the  orbit  (see  p.  182). 

GOUT. 

The  influence  of  gout  in  producing  kidney  disease  renders 
it  a  powerful  indirect  cause  of  the  retinal  affection  which 
accompanies  albuminuria.  There  are,  however,  other  oph- 
thalmoscopic  changes  which  are  to  be  ascribed  with  more 
or  less  probability  to  the  gouty  state .  of  the  blood.  They 
are  seldom  seen  in  corresponding  general  conditions,  except 
in  persons  who  are  the  subjects  of  gout,  so  that  they  become 
important  as  evidence  of  a  constitutional  state  which  may 
have  been  previously  obscure. 

(1.)  Htemorrhagic  Retinitis. — The  frequency  with  which  the 
subjects  of  this  affection  present"  a  history  of  gout  was  first 
pointed  out  by  Hutchinson,1  and  the  influence  seems  well 
established,  although  its  extent  is  possibly  exaggerated 
The  extravasations  maybe  small,  flame-shaped,  and  scattered 
over  the  whole  fundus.  They  are  usually  present  in  one  eye 
only,  often  the  left.  Haemorrhages  may  recur  for  a  long 
period.  Hutchinson  believes  that  they  may  occur  in  young 
persons  from  inherited  gout.  He  suggested  that  their  cause 
might  be  thrombosis  in  the  central  retinal  vein,  from  which 
Michel  has  shown  that  extensive  haemorrhages  may  result 
(see  p.  31).  The  obstruction  in  the  vein  is  probably  only  a 
very  partial  one,  however,  in  many  of  the  cases,  since  there 
is  no  such  intense  nervous  engorgement  as  has  been  found 

1  "Trans.  Clin.  Soc.,"  vol.  xi.  p.  132.  See  also  -''Trans.  Ophth.  Soc.," 
vol.  i.  1881,  p.  26. 


268  MEDICAL   OPHTHALMOSCOPY. 

when  the  thrombosis  was  nearly  or  quite  complete.  Again, 
the  well-known  tendency  to  recurrence  of  the  extravasations 
is  in  favour  of  the  cause  being  a  partial  obstruction,  such  as 
would  result  from  the  gradual  formation  of  a  parietal 
thrombus  at  one  or  more  points  in  the  vein,  in  connection 
with  changes  in  or  around  its  walls. 

Gralezowski  has  also  described  haemorrhages  leaving  white 
patches  of  "  sclerosis  "  as  occurring  in  gouty  persons. 

(2.)  Retro-bulbar  Neuritis, — "We  have  learned  that  spon- 
taneous inflammation  of  nerve  trunks  and  plexuses,  on  one 
side  only,  and  occurring  after  the  age  of  thirty  or  forty,  is 
seldom  due  to  any  other  cause  than  gout.  Such  neuritis 
means  always  primary  perineuritis.  This  would  lead  us  to 
expect  that  such  an  influence  would  be  exerted  frequently 
on  a  nerve  so  prone  to  suffer  from  inflammation  as  the  optic, 
but  inflammation  of  its  sheath  behind  the  eye  is  less  common 
in  ordinary  gout  than  might  be  anticipated.  Acute  or  sub- 
acute  inflammation  is,  however,  met  with  in  young  adults  in 
whom  no  other  cause  can  be  traced,  and  in  whom  this  cause 
is  never  absent, — facts  that  confirm  the  relation  to  inherited 
gout  long  maintained  by  Mr.  Hutchinson.  The  character- 
istics of  these  cases  are,  of  course,  the  greater  degree  of  affec- 
tion of  sight  than  corresponds  to  the  visible  changes  in  the  optic 
disc  ;  the  tendency  to  irregular  defects  in  the  field  of  vision  ; 
and  the  strong  tendency  to  the  affection  of  the  second  nerve, 
not  by  extension  through  the  commissure,  but  by  an  inde- 
pendent symmetrical  morbid  process.  This  always  proves 
a  general  cause.  Occasionally  the  chiasma  is  invaded.  The 
part  of  the  nerve  diseased  differs,  and  with  it  the  affection 
of  sight  varies.  Probably,  in  some  cases,  the  affection  com- 
mences at  the  chiasma,  and  simulates  compression  by  a 
tumour.  When  the  process  is  far  back,  no  signs  of  inflam- 
mation may  be  seen  within  the  eye,  or  only  such  as  are  slight 
and  equivocal,  but  atrophy  slowly  supervenes. 

There  is  often  much  pain — for  the  subjects  are  commonly 
prone  to  neuralgia.  As  a  rule  other  orbital  nerves  escape — a 
contrast  to  the  rheumatic  cellulitis  and  perineuritis  mentioned 
above  (p.  182). 


LEAD    POISONING.  269 


LEAD  POISONING. 

The  eye  is  occasionally  affected  in  lead  poisoning,  apart 
from  the  effects  of  induced  kidney  disease.  It  may  suffer  in 
three  ways.  There  may  be  (1)  amblyopia,  usually  transient, 
without  ophthalmoscopic  changes ;  (2)  atrophy  of  the  optic 
nerve  ;  (3)  optic  neuritis. 

The  occurrence  of  blindness  in  lead  poisoning  has  long 
been  known.  Some  well-marked  cases  were  published  by 
Duplay  in  1834.1  In  what  v.  Graefe  called  "  the  pre-ophthal- 
moscopic  period,"  the  transient  amblyopia  attracted,  however, 
more  attention  than  the  graver  forms  of  affection,  so  that 
Tanquerel  des  Planches  spoke  of  the  amblyopia  as  almost 
invariably  passing  away.  Optic  nerve  atrophy  in  lead 
poisoning  was  first  described  by  Hirschler  in  1866,2  and 
optic  neuritis  by  Meyer  in  1868.3  Attention  was,  however, 
especially  called  to  the  affection  by  the  publication  of  an 
important  series  of  cases  by  Hutchinson  in  1871 .4 

(1.)  The  transient  amblyopia,  without  ophthalmoscopic 
changes,  is  usually  sudden  in  onset,  and  may  be  complete- 
It  has  been  observed  in  some  cases  of  acute  saturnism  after 
but  short  exposure  to  the  exciting  cause.  It  commonly  soon 
passes  away,  and  is  probably  due  to  a  direct  effect  of  the  lead 
on  the  nerve  centres,  analogous  to  the  temporary  amaurosis 
of  uraemia  and  diabetes.  In  one  case  recorded  by  Fano  there 
was,  for  some  months,  a  periodical  transient  failure  of  sight 
at  the  same  hour  each  day. 

Hemiansesthesia  has  been  observed  (chiefly  on  the  Con- 
tinent) in  consequence  of  lead  poisoning.  It  is  apparently 
of  functional  origin,  and  may  be  due  to  the  same  mechanism 
as  the  transient  amblyopia.  The  two  coincided  in  a  remark- 
able case  which  has  been  recorded  by  Landolt,5  although  in 

1  "  Arch.  Gen.  de  Med.,"  1834. 

2  "  Wien.  Med.  Wochenschr.,"  1866,  N"os.  6  and  7.     It  is  not  easy  to  say, 
from  the  account  of  the  case,  whether  neuritis  was  present  or  not.     The 
disc  is  spoken  of  as  being  grey  and  having  lost  its  transparency. 

'  3  "L'UnionMed.,"No.  78. 

4  "  Ophth.  Hosp.  Rep.,"  vol.  vii.  p.  6. 

5  "Ann.  d'Oculistique,"  vol.  Ixxxiii.  March,  1880,  p.  165. 


'270  MKDICAL   OPHTHALMOSCOPY. 

this  case  it  is  very  doubtful  whether  the  symptoms  were  due 
entirely  to  functional  disturbance.  Hemiplegic  weakness, 
hemianoesthesia,  and  amblyopia  came  on  together.  The  loss 
of  power  lessened,  but  the  loss  of  sensibility  and  affection  of 
sight  persisted.  Six  months  later,  the  field  of  vision  of  the 
eye  on  the  affected  side  presented  slight  peripheral  limitation 
and  a  central  scotoma  with  complete  loss  of  colour- vision. 
The  other  field  presented  two  concentric  annular  scotomata 
with  partial  loss  of  colour- vision,  blue,  violet,  and  yellow  being 
lost,  red  and  green  not  lost.  Acuity  in  each  was  reduced  to 
counting  fingers.  The  discs  were  merely  greyish  red  in  tint, 
the  veins  large.  The  application  of  an  electro-magnet  is  said 
to  have  restored  sensibility  to  the  side,  to  have  restored  colour- 
vision,  and  to  have  improved  acuity,  but  the  scotomata  re- 
mained till  the  patient  resumed  his  work  and  was  lost  sight  of. 

Stood1  has  published  several  cases  where  there  was  pro- 
gressive concentric  contraction  of  both  fields,  both  for  white 
light  and  for  colours.  Sometimes  there  was  slight  neuritis. 
Central  scotoma  was  present  in  a  few  cases  only. 

(2.)  In  amblyopia  of  long  duration  it  is  common  to  find 
the  signs  of  atrophy  of  the  optic  nerves.  The  discs  are  sharp- 
edged,  pale,  and  often  greyish,  the  arteries  small.  It  is  said 
that  the  atrophy  may  be  from  the  first  unattended  by  vascular 
changes  (Horner).  In  a  considerable  number  of  cases,  how- 
ever, which  have  been  seen  in  an  early  stage,  a  condition 
of  simple  congestion  of  the  discs  has  been  found.  The  tint 
is  uniformly  red,  with  softened  edges,  with  little  or  no 
swelling.  Gradually  the  redness  fades,  and  a  reddish-grey 
atrophy  results,  often  with  distinct  white  lines  along  the 
narrowed  vessels.  Sight  has  been  much  affected  in  all  the 
recorded  cases,  the  acuity  of  vision  impaired,  and  the  field 
presenting  a  central  or  peripheral  defect.  The  loss  commonly 
progresses  until  even  quantitative  perception  of  light  may 
be  lost.  This  congestive  atrophy  is  usually  double,  but,  as 
a  case  recorded  by  Hutchinson  shows,  the  affection  of  one 
eye  may  precede  that  of  the  other. 

1  "Arch.  f.  Ophth.,"  1884,  iii.  p.  215. 


LEAD    POISONING.  271 

(3.)  Occasionally  cases  of  lead  poisoning  present  much 
more  pronounced  inflammatory  changes — considerable  papil- 
litis  with  swelling,  obscuration  of  the  edge  of  the  disc, 
concealment  of  vessels,  and  haemorrhages,  especially  at  the 
margin  of  the  swelling.  The  arteries  beyond  the  swelling 
are  commonly  narrow ;  the  veins  may  be  distended  or  of 
normal  size.  An  instance  of  this  form  of  neuritis  is  shown 
at  PL  VII.  6.  The  affection  is  almost  always  double,  and 
usually  entails  considerable  amblyopia.  There  is  reason  to 
believe,  however,  that  slight  degrees  of  neuritis  are  not 
uncommon  in  lead  poisoning  without  any  affection  of  sight. 
I  have  seen  one  such  case,  and  the  general  use  of  the  oph- 
thalmoscope in  medical  practice  will  probably  show  it  to  be 
not  an  infrequent  occurrence.  Pronounced  neuritis  may 
subside  into  atrophy  having  the  characters  of  "  consecutive 
atrophy,"  leaving  a  dull- white,  full-looking  disc,  with  narrow 
arteries.  Or  the  neuritis  may  clear  and  sight  be  recovered. 
In  a  case  recorded  by  Schrceder,  there  was  well-marked 
papillitis  with  haemorrhages,  without  any  pronounced  cerebral 
symptoms,  although  there  was  some  palsy  of  both  sixth 
nerves.  There  was  no  central  scotoma.  Eapid  improvement 
occurred  under  treatment.  It  is  important  to  remember 
that  the  affection  of  sight  in  these  cases  may  be  in  part  due 
to  the  direct  effect  of  the  lead  on  the  nervous  system,  which 
has  been  already  mentioned.  This  is  the  more  likely  when, 
as  in  many  recorded  cases,  loss  of  sight  comes  on  suddenly. 
The  transient  amblyopia,  mentioned  above,  has  been  noted 
in  association  with  neuritis l  as  well  as  with  normal  ophthal- 
moscopic  appearances. 

These  ocular  changes  commonly  occur  in  chronic  cases  of 
lead  poisoning,  which  have  presented  toxic  symptoms  for 
some  time,  often  for  years,  previously,  and  they  may  coin- 
cide with  an  increase  of  the  other  symptoms.  It  must  be 
remembered,  however,  that  the  manifestations  of  lead  are 
very  irregular,  and  any  one  may  be  absent  or  may  alone  be 
present.  In  cases  of  very  recent  intense  lead  poisoning, 

1  A  case  reported  by  Strieker  from  Traube's  Clinique,  and  quoted  by 
Abadie  ("Mai.  des  Yeux"), 


272  MEDICAL   OPHTHALMOSCOPY. 

toxic  amblyopia  and  neuritis  are  apparently  more  common 
than  atrophy.  A  case  in  which  neuritis,  going  on  to  atrophy, 
occurred  in  a  girl  of  seventeen,  after  four  years'  work  in  a 
type  foundry,  has  been  recorded  by  Hirschberg.1  She  suf- 
fered also  from  various  nerve-troubles. 

In  many  cases  of  lead  poisoning  the  occurrence  of  neuritis 
coincides  with  symptoms  of  cerebral  disturbance,  headache, 
convulsions,  delirium,2  &c.  The  case  figured  in  PL  VII.  6 
presented,  at  the  same  time  as  the  neuritis,  much  mental 
disturbance,  and  both  symptoms  passed  away  together.  In 
a  fatal  case  of  this  description,  recorded  by  R.  Atkinson,3 
there  were  no  naked-eye  changes  in  the  meninges  or  brain, 
but  lead  was  found  in  it  in  quantity  equivalent  to  five  grains 
in  the  whole  brain.  This  association  of  cerebral  disturbance 
with  optic  neuritis  in  these  cases  is  probably  more  than  a 
coincidence,  and  the  analogous  fact  as  regards  albuminuric 
neuritis  (p.  222)  may  be  borne  in  mind. 

The  diagnosis  of  saturnine  atrophy  and  neuritis  rests 
especially  on  the  recognition  of  the  signs  of  lead  poisoning, 
the  line  on  the  gums,  the  occurrence  of  gout,  of  colic,  of 
wrist-drop,  and  the  presence  of  anaemia.  It  is  only  by  these 
symptoms  that  the  neuritis  can  be  distinguished  from  that 
of  primary  encephalic  affections.  The  possibility  of  a  renal 
neuritis  in  cases  of  lead  poisoning  must  be  borne  in  mind. 
It  is  highly  probable  that  in  at  least  one  published  case  the 
retinal  change  was  due  to  the  albuminuria  rather  than  to  the 
lead.  Albuminuric  retinitis  is  not  uncommon  in  cases  of 
chronic  lead  poisoning  of  long  duration.  Again,  an  intra- 
cranial  syphilitic  growth  may  coexist  with  lead  poisoning, 
and  give  rise  to  ocular  symptoms,  and  as  the  ordinary  treat- 
ment for  lead  poisoning  may  cause  the  disappearance  of  the 
syphilitic  lesion,  the  error  of  attributing  the  ocular  conditions 
to  the  toxic  influence  of  the  lead  may  very  easily  be  made. 

1  "Arch.  f.  Augenkrankheiten,"  1879,  p.  9. 

2  This  is  an  old  observation.     Tanquerel  des  Planches  described  saturnine 
amaurosis  as  the  accompaniment  of  encephalopathia  and  colica  saturnina,  and 
stated  that  in  cases  of  this  kind  no  material  change  is  to  be  found  in  the 
brain  ("Traite  des  Mai.  de  Plomb.,"  1839,  torn.  ii.  pp.  211  and  235). 

3  "  Lancet,"  1878,  i.  p.  784. 


CHRONIC   ALCOHOLISM.  273 

The  prognosis  in  all  forms  of  change  in  the  optic  disc  must 
be  cautious.  It  is  least  grave  in  the  case  of  toxic  amblyopia, 
next  in  cases  of  pronounced  neuritis,  especially  of  acute 
course,  less  so  in  cases  of  chronic  congestive  change,  and  in 
pronounced  atrophy  it  is  very  unfavourable.  Of  fourteen 
cases  of  various  forms,  collected  by  Lespille-Moutard,1  nine 
progressed  to  blindness. 

The  treatment  is  essentially  that  for  the  general  state, 
but  local  applications,  leeching  and  counter-irritation,  have 
.appeared  useful  in  some  cases. 

CHRONIC  ALCOHOLISM. 

Atrophy  of  the  optic  discs,  sometimes  of  one  only,  some- 
times of  both,  is  occasionally  met  with  in  the  subjects  of 
chronic  alcoholism,  to  which  it  is  apparently  due.  It  is  said 
to  occur  especially  in  sedentary  drinkers,  to  be  more  com- 
mon on  the  Continent  than  in  this  country,  and  to  result 
from  spirit-drinking  rather  than  from  wine.  Hence,  accord- 
ing to  Rominee,2  it  is  much  more  common  in  the  north  of 
France,  where  much  cheap  brandy  is  consumed,  than  in  the 
wine-producing  districts  of  the  south.  Amblyopia  may 
precede  any  ophthalmoscopic  change,  and  is  characterized  by 
a  central  dimness  or  defect  (Forster),  very  similar  to  that 
met  with  from  tobacco,3  but  said  to  be  more  exactly  central 
(Hirschberg).  Before  there  is  recognizable  defect  for  white 
light,  a  defect  for  red  may  be  discovered,  extending  from  the 
fixing  point  to  the  blind  spot  and  a  little  beyond  each.  To 
detect  it  in  slight  cases  the  ordinary  colour  tests  do  not 
suffice,  since  the  coloured  object  should  not  be  more  than  five 
millimetres  in  diameter.  Extensive  loss  of  vision  for  certain 
colours,  as  green  and  violet,  has  also  been  described  by 

1  "  These  de  Paris."  1878.  z  "  Recueil  d'Ophth.,  1881,"  Nos.  1,  2. 

3  It  should  be  remarked  that  the  symptoms  here  described  (in  accordance 
with  the  opinion  of  most  authorities)  as  due  to  alcohol,  are  believed  by  some 
to  be  met  with  only  in  drinkers  who  are  smokers,  and  to  be  really  due  to 
tobacco.  See  Nettleship,  "  St.  Thomas's  Hosp.  Rep.,"  1879.  If  the  fact  is 
true  that  smokers  who  drink  suffer  less  from  tobacco  amblyopia  than  do 
abstainers  from  alcohol,  additional  doubt  is  thereby  cast  on  the  influence  of 
the  latter  in  causing  the  same  symptoms. 

T 


274  MEDICAL   OPHTHALMOSCOPY. 

Gralezowski  as  a  symptom  of  retinal  anaesthesia,  in  some  cases 
of  chronic  alcoholism.  It  is  probable,  indeed,  that  the  per- 
ception of  green  is  commonly  lost  as  well  as  that  of  red,  both 
colours  appearing  grey.1 

A  stage  of  congestion,  before  the  onset  of  the  atrophy,  has 
been  described  by  Allbutt  and  others.  The  appearances  were 
generally  those  already  described  as  "  Simple  Congestion  " 
(p.  44),  uniform  redness  of  the  disc,  with  softened  edges. 
The  disc  gradually  becomes  paler,  and  ultimately  passes  into 
white  or  greyish  atrophy,  often  with  small  vessels.  UhthofP 
examined  a  thousand  cases  of  severe  alcoholism  in  inmates  of 
asylums,  and  found  that  13*9  of  these  suffered  from  patho- 
logical whiteness  of  the  temporal  half  of  each  disc,  with  a 
central  scotoma  in  every  case.  He  found  this  condition  in 
only  one  out  of  a  hundred  apparently  healthy  men,  whom 
he  selected  for  comparison.  Moreover,  Moeii3  has  stated  that 
he  has  detected  changes  in  the  optic  disc  in  15  per  cent,  of 
the  cases  of  delirium  tremens  examined  by  him.  When 
the  condition  of  the  nerve  has  been  ascertained  by  micro- 
scopical examination,  granular  degeneration  of  the  nerve 
fibres  has  been  found  in  some  cases.  Out  of  seven  cases 
examined  post-mortem  by  Uhthoff,  two  showed  distinct 
interstitial  neuritis,  with  marked  increase  of  the  connective 
tissue.  The  changes  were  most  distinct  just  behind  the 
globe,  and  did  not  extend  far  back.  I  believe  that  con- 
gestion, sometimes  with  slight  oedema,  is  occasionally  to  be 
recognized  in  the  cases  of  chronic  alcoholism.  It  is,  no 
doubt,  an  analogous  condition  to  that  change  in  the  meninges 
which  leaves  the  thickening  and  opacity  often  to  be  found 
after  death. 

The  progress  of  the  atrophy  is  slow,  and  the  prognosis 
better  than  in  many  other  forms;  considerable  good  being 
effected,  especially  in  the  pre-atrophic  stage  of  amblyopia,  by 
strychnia  and  tonics.  Complete  recovery  of  vision  may  take 
place,  although  the  pallor  of  the  disc  continues.4 

1  Nuel:  "Ann.  d'Oculistique, "  Sept.  1878. 

2  "Ophth.  Rev.,"  vii.  p.  100. 

3  "  Neurol.  Centralbl.,"  1884,  p.  260. 

4  Berry:  "Ophth.  Rev.,"  iii.  1884,  p.  101. 


TOBACCO    POISONING.  275 

In  a  fatal  case  of  alcoholism,  Lawford  found  during  life 
widespread  cloudiness  of  the  retina,  with  normal  discs,  and 
without  any  central  colour  scotoma.  After  death  the  retina 
of  one  eye  was  examined  hy  Edmunds1  and  himself ;  there 
was  oedema  of  the  nerve-fibre  and  ganglion-cell  layers,  and 
in  the  outer  nuclear  layer  there  were  spaces,  filled  with  a 
clear  effusion,  between  the  Miillerian  fibres.  In  a  case  of 
severe  alcoholic  paralysis  related  by  Ord,2  well-marked 
double  retinitis  was  found,  with  white  patches. 

In  acute  alcoholism,  ophthalmoscopic  changes  are  not 
commonly  present.  In  one  case  Jager  found  a  condition 
of  diffuse  retinitis,  with  numerous  haemorrhages,  in  a  patient 
suffering  from  delirium  tremens.  This  was  undoubtedly  an 
exceptional  complication,  but  we  need  more  facts  regarding 
slight  changes, 

TOBACCO  POISONING. 

The  occurrence  of  defective  sight  from  tobacco  smoking 
was  described  in  1854  by  Mackenzie,  who  was  inclined  to 
attribute  most  cases  of  amaurosis  to  this  cause.  The  subject 
attracted  little  attention  until  Hutchinson,3  in  1864,  brought 
forward  facts  to  show  that  amblyopia,  accompanied  by  slight 
ophthalmoscopic  changes,  often  results  from  this  cause,  while 
Fcirster4  and  Hirschberg5  have  demonstrated  that  the 
affection  of  sight  uniformly  presents  special  characteristics. 
The  relation  between  these  symptoms  and  tobacco  smoking 
has  indeed  been  doubted  by  some  writers,  but  must  be 
regarded  as  now  among  the  best  established  facts  of 
ophthalmology.6 

Fcirster  has  remarked  that  the  sight  suffers  from  tobacco 

1  "Trans.  Ophth.  Soc.,"  ix.  1889,  p.  137. 

2  "Lancet,"   Feb.   11,   1888;    see  also  Sharkey,  "Trans.   Path.   Soc.   of 
Lond.,"  1889,  p.  359. 

3  "Lond.     Hosp.    Rep.,"   1864;    see   also    "Med.-Chir.    Trans.,"   1867; 
"  Ophth.  Hosp.  Rep.,"  1871  and  1876. 

*  Graefe  u.  Saeniisch's  "Handbuch,"  vol.  vii.  p.  201. 

5  "Deutsche  Zeitschrift  f.  Prakt.  Med.,"  1878. 

6  For  an  excellent  rtmmi  of  what  is  known  on  the  subject,  see  Nettleship's 
"Notes  on  the   Diagnosis  of  Tobacco  Amblyopia,"  "St.   Thomas's  Hosp. 
Rep."  1879. 


276  MEDICAL    OPHTHALMOSCOPY. 

generally  between  thirty-five  and  sixty-five  years  of  age, 
and  believes  that  tobacco  is  not  so  well  borne  during  the 
second  half  of  life  as  during  the  period  of  full  vigour. 
Several  of  Hutchinson's  cases,  however,  were  under  thirty. 
Mental  trouble,  with  its  accompanying  sleeplessness  and  loss 
of  appetite,  seems  often  to  be  the  determining  cause  of  the 
poisoning  in  men  long  habituated  to  the  use  of  tobacco,  and 
that  even  where  there  is  no  history  of  a  recent  increased 
indulgence.  It  has  been  thought  that  the  disease  occurs 
more  frequently  among  abstainers  from  alcohol  than  among 
those  who  take  alcohol,  and  some  facts  mentioned  by  Nelson1 
seem  to  show  that  in  the  latter  the  affection  may  come  on 
more  slowly. 

The  failure  of  sight  is  gradual  and  usually  equal  in  both 
eyes,  unaccompanied,  as  a  rule,  with  headache  or  other 
cerebral  symptoms.  It  is  nearly  always  more  marked  in  a 
bright  than  in  a  dull  light.  The  characteristic  of  the  failure 
is  the  presence  of  a  defect  in  the  centre  of  the  field  of  vision, 
a  "  central  scotoma,"  transversely  oval  or  oblong,  extending 
from  the  fixing  point  to  the  blind  spot,  and  often  embracing 
both.  It  is  a  relative,  not  an  absolute  scotoma;  there  is 
dimness,  not  loss,  of  sight,  and  the  failure  is  greater  for 
certain  colours  (green  and  red)  than  for  white.  If  the  defect 
is  slight,  the  coloured  object  must  be  of  small  size  in  order  to 
detect  it.  The  scotomata  are  symmetrical,  or  nearly  so,  in  the 
two  eyes  (see  Figs.  60,  61,  p.  126),  and  seem  to  begin  most 
commonly  at  or  near  the  fixing  point  (Leber,  Treitel,  Nettle- 
ship).  Nelson,  however,  has  described  a  case  in  which  the 
scotoma  surrounded  the  blind  spot  and  the  fixing  point  was 
free.  The  variations  in  the  exact  limits  of  colour  fields  in 
different  individuals  and  with  different  degrees  of  illumina- 
tion render  it  uncertain  whether  there  is  a  peripheral 
limitation  of  these  fields ;  such  limitation  is  certainly  not 
always  present,  but  probably  may  be  in  severe  cases  (Treitel, 
see  also  Fig.  59,  p.  126).  The  symmetry  of  the  scotomata 
is  anatomical,  not  functional,  and  indicates  a  morbid  process 
in  the  orbital  portions  of  the  optic  nerve,  doubtless  in  its  axis 

1  "  Brit.  Med.  Jour.,"  1880,  ii.  p.  774. 


QUININE.  277 

(see  p.  123).  Sometimes  a  stage  of  simple  congestion,  a 
"  hazy  disc,"  slight  uniform  redness,  with  soft  edges,  without 
noticeable  swelling,  may  be  the  first  change.  In  exceptional 
instances,  slight  papillitis,  with  a  few  small  retinal  haemor- 
rhages near  the  disc,  has  been  found ;  in  these  cases  the 
failure  of  sight  has  been  unusually  rapid,  and  there  has  been  a 
history  of  recent  great  excess  in  tobacco.  Later  there  is  a 
slight  degree  of  atrophy. 

The  treatment  consists  essentially  in  the  removal  of  the 
cause.  Tonics  and  hypodermic  injections  of  strychnine  are 
also  of  use,  especially  in  the  pre-atrophic  stage.  Hutchinson 
believes  the  prognosis  in  most  cases  to  be  good,  three-fourths 
of  his  cases  having  recovered,  or  presented  great  improve- 
ment in  sight.  Age  does  not  render  the  prognosis  worse.1 

QUININE. 

Quinine  in  large  doses  may  cause  complete  temporary 
amaurosis.  Many  well-marked  cases  have  been  recorded.'2 
The  amount  of  quinine  which  caused  the  symptoms  varied 
from  a  minimum  of  80  grains  in  thirty  hours,  to  a  maximum 
of  1,300  grains  in  three  days.  In  most  of  these  cases  the 
quinine  was  given  for  malaria,  but  that  the  affection  of  sight 
was  due  to  the  former,  and  not  to  the  latter,  is  proved  by  the 
definite  and  peculiar  character  of  the  symptoms,  and  by  the 
fact  that,  in  some  other  cases,  the  patient  was  not  suffering 
from  any  disease,  and  the  quinine  was  taken  by  accident. 
In  all  the  cases  the  loss  of  sight  was  at  first  complete,  and  was 
associated  with  loss  of  hearing.  The  deafness  soon  passed 
away,  usually  in  twenty-four  hours.  The  blindness  con- 

1  For  much  valuable  information  on  this  subject,  the  reader  is  referred  to 
the   "Report  on  Toxic  Amblyopia,"  "Trans.  Ophth.  Soc.,"  vol.  vii.  1887, 
p.  85. 

2  Giacomini :  "  Ann.  Univers.  di  Med.,"  1841  ;  Graefe  :  "Arch.  f.  Ophth.  ,'> 
iii.  pt.  2,  p.  396  ;  Roosa  :  "Archives  of  Ophthalmology,"  vol.  iii.  p.  3,  and 
ix.  pt.  1  ;  Gruening :  ibid.  vol.  x.  pt.  1,  p.  81  ;  Vorhies :  "  Trans.  American 
Med.   Assoc.,"    1879;   Michel:    "Archives  of  Ophthalmology,"   x.   pt.    1, 
p.  102  ;  and  Knapp  :  ibid.  x.  pt.  2,  p.  220.     The  last  paper  contains  a  very 
full  discussion  of  the  subject.     See  also  papers  by  Browne,   "Trans.  Ophth. 
Soc.,"  vol.   vii.  p.   193  (with  references  to  previously  recorded  cases),  and. 
Nettleship,  in  same  volume,  pp.  218,  219. 


278  MEDICAL   OPHTHALMOSCOPY. 

tinned  for  a  longer  time,  which  varied  according  to  the  dose. 
Central  vision  returned  to  the  normal  in  a  few  days,  weeks, 
or  months,  but  the  peripheral  vision  continued  lost  for  a 
very  long  time.  This  contraction  of  the  visual  field  after 
the  return  of  central  vision  seems  to  be  invariable,  and  the 
restricted  field  is  usually  transversely  oval.  Colour- vision  is 
also  impaired.  The  pupils  are  dilated,  and  during  total 
blindness  are  irresponsive  to  light,  but  act  to  accommodation 
(Gruening).  The  ophthalmoscope  has  shown  pallor  of  the 
disc,  and  in  all  cases  a  remarkable  diminution  in  size  of 
the  retinal  vessels,  which  may  be  reduced  to  threads,  and 
emptied  by  the  slightest  pressure  on  the  eye.  A  cherry-red 
spot  at  the  macula  has  been  noticed  (Gruening).  Yorhies 
found  the  choroidal  vessels  also  empty.  In  the  case  of 
Giacomini,  where  three  drachms  were  taken  at  a  single  dose, 
there  was  loss  of  consciousness  at  the  onset.  In  all  cases 
a  considerable  degree  of  recovery  has  ultimately  occurred. 
In  the  most  severe  case  (Michel),  in  which  seven  drachms  of 
quinine  were  taken,  there  was  no  improvement  for  several 
months,  and  it  was  thought  that  sight  was  permanently  lost ; 
nevertheless,  fifteen  months  afterwards  acuity  of  vision  was 
nearly  normal,  although  the  fields  were  much  restricted. 
The  vessels  had  increased  in  size,  but  were  still  much  below 
the  normal.  Recovery  in  six  weeks  has  followed  a  dose  of 
five  drachms.  Whilst  the  symptoms  are  passing  off,  relapses 
may  be  produced  by  insignificant  doses  of  quinine. 

BISULPHIDE  OF  CARBON. 

Bisulphide  of  carbon  was  the  apparent  cause  of  a  "  peri- 
neuritis,"  ending  in  partial  atrophy,  in  a  case  recorded  by 
Galezowski.1  Atrophy  of  the  optic  nerves  is  also  seen,  not 
very  rarely,  among  the  workers  in  india-rubber  factories, 
in  which  bisulphide  of  carbon  is  used.  A  special  committee 
of  the  Ophthalmological  Society  (consisting  of  Messrs. 
Frost,  Gunn,  and  Nettleship)  was  appointed  to  investigate 
this  form  of  toxic  amblyopia,  and  in  their  very  valuable 

i  Galezowski  :  "  Des  Amblyopies  et  Amauroses  Toxiques,"  p.  141. 


ACUTE    GENERAL    DISEASES.  279 

report1  on  the  whole  subject  they  tabulate  twenty-four  cases 
of  amblyopia  coming  on  after  the  development  of  other 
symptoms  indicating  great  depression  of  the  whole  nervous 
system.  In  most  cases  examined  there  was  a  distinct  central 
colour-scotoma,  and  the  ophthalmoscope  showed  pallor  and 
blurring  of  the  edge  of  the  optic  disc,  with  loss  of  trans- 
parency of  the  retina  for  some  distance  from  the  disc. 

OTHER  POISONS. 

Silver  poisoning  is  said  to  be  accompanied  by  amblyopia, 
in  addition  to  the  other  symptoms  of  argyria.  No  ophthal- 
moscopic  changes  have,  however,  been  recorded,  but  silver 
has  been  found  in  the  eyeball  (sclerotic  sheath  of  the  optic 
nerve,  &c.),  by  Reimer,  deposited  in  small  round  granules. 
The  effect  of  silver  is  closely  analogous  to  that  of  lead.  It 
may,  as  I  have  seen,  lead  to  wrist-drop,  gout,  and  albumi- 
nuria,  and  it  is  therefore  highly  probable  that  the  same 
ocular  changes  may,  in  some  cases,  result. 

In  mercurial  poisoning  amblyopia  has  been  observed ;  in 
one  case  optic  neuritis  existed,2  and  in  another  optic  nerve 
atrophy.3  Of  ocular  changes  in  copper  and  phosphorus 
poisoning  nothing  is  known. 

Salicylic  acid  may  cause  amblyopia,  but  without  changes  in 
the  fundus  oculi.  The  same  effect  has  been  observed  from 
salicylate  of  soda.4 

ACUTE   GENERAL   DISEASES. 
TYPHUS  FEVER. 

Loss  of  sight  has  been  many  times  observed  during  con- 
valescence from  typhus  fever,5  and  subsequently  atrophy  of 

1  "Trans.  Ophth.  Soc.,"  vol.  v.  1885,  p.  157. 

-  Square:  "Ophth.  Hosp.  Rep.,"  vi.  p.  54. 

s  Galezowski  :  "  Des  Amblyopies  et  Amauroses  Toxiques,  p.  141. 

4  Gatli  :   "  Gaz.  degl.  Ospital,"  1880,  i.  4. 

5  In  a  considerable  number  of  the  cases  recorded  abroad  it  is  doubtful 
•whether  the  disease  was  typhus  or  typhoid  fever.     The  cases  on  which  the 
.statements  in  the  text  are  founded  appear  to  have  been  true  typhus. 


280  MEDICAL   OPHTHALMOSCOPY. 

one  or  both  optic  nerves  has  been  found.  In  some  of  these 
cases  there  have  also  been  cerebral  symptoms,  as  in  a  case 
recorded  by  Benedikt,  in  which  left  hemiplegia  was  accom- 
panied by  atrophy  of  the  right  optic  nerve.  In  such  cases, 
probably,  the  atrophy  was  the  result  of  a  cerebral  lesion.  In 
other  cases  there  were  no  symptoms  except  those  in  the  eye, 
and  a  primary  affection  of  the"  optic  nerve  appeared  to  have 
occurred.  In  some  cases  these  ophthalmoscopic  changes  have 
been  those  of  simple  atrophy,  but  in  others,  where  the 
affection  of  sight  was  first  noticed  during  convalescence, 
optic  neuritis  has  been  found.1  In  a  case  at  Great  Ormond 
Street  Hospital,  marked  papillitis  was  found  by  Penrose  and 
Gunn  during  the  height  of  the  fever.  Of  the  origin  of  the 
neuritis  nothing  is  known. 

TYPHOID  FEVER. 

The  occurrence  of  amblyopia  and  amaurosis  during  conva- 
lescence from  typhoid  is  well  established,2  although  rare.  It 
may  or  may  not  be  attended  with  ophthalmoscopic  changes. 
In  the  latter  case  the  prognosis  is  favourable  ;  the  affection 
usually  passes  away  in  the  course  of  two  to  eight  weeks. 
The  form  of  amblyopia  varies ;  anaesthesia  of  the  retina  has 
been  observed  by  Leber,  and  an  annular  defect  in  the  field 
by  Hersing. 

When  ophthalmoscopic  changes  have  been  observed,  there 
has  been  simple  atrophy,  single  or  double,  without  preceding- 
inflammation  ;  or  double  neuritis  may  be  present,  ending  in 
atrophy,  partial  or  complete,  or  less  commonly  in  recovery. 
Hutchinson  has,  for  instance,  recorded3  the  case  of  a  boy 
whose  sight  failed  at  three  years  and  a  half,  two  to  four 
weeks  after  a  fever  with  diarrhoea  and  headache,  a  sister 
having  suffered  from  similar  symptoms  at  the  same  time. 
Symmetrical  neuritis  was  found,  and  ten  years  later  white 

1  Teale  :  "  Med.  Times  and  Gazette,"  May  11,  1867.     Chisholm  :  "  Ophth. 
Hosp.  Rep.,"  vol.  vi.  p.  214. 

-  Nothnagel  :  "  Deut.  Arch,  fur  Kl.  Med.,"  1872,  ix.  p.  480. 
3  "Ophth.  Hosp.  Rep.,"  ix.  p.  125. 


RELAPSING    FEVER.  281 

atrophy  with  small  vessels.  The  neuritis  is  so  rare  that 
Leber  suggests,  as  Stellwag  v.  Carion  had  suggested  long 
before,1  that  the  cases  in  which  it  is  found  may  really 
have  been  cases  of  meningitis  which  have  been  mistaken 
for  typhoid  fever — an  error  not  very  rare.  It  must  be 
remembered,  however,  that  neuritis  does  occasionally  follow 
other  acute  specific  diseases.  It  has  been  thought  that 
the  cases  accompanied  by  hypersemia  of  the  discs  are  cases 
complicated  by  meningitis;  but  meningitis,  except  as 
secondary  to  suppuration  in  the  ear,  is  exceedingly  rare 
in  typhoid  fever.  Sir  William  Jenner  has  informed  me 
that  he  has  never  seen  it.  It  does  not  appear  from  Dr. 
Murchison's  work  on  Fevers,  that  he  had  ever  met  with 
a  case.  To  infer  meningitis  in  consequence  of  extreme 
delirium  or  coma  is  certainly  not  warranted  by  pathological 
facts. 

Extreme  narrowing  of  the  retinal  arteries,  on  both  sides, 
with  pallor  of  the  disc  and  loss  of  sight,  was  found  by 
Heddaens2  in  a  case  of  great  emaciation  after  typhoid.  On 
good  food  the  arteries  regained  their  normal  size,  but  the 
disc  remained  pale,  and  sight  did  not  improve  beyond  -^. 

Gralezowski3  and  Snell4  have  observed  embolism  of  the 
central  artery  of  the  retina  during  convalescence  from 
typhoid. 

RELAPSING  FEVER. 

.  It  is  well  known  that  extensive  intra-ocular  inflammation 
is  apt  to  follow  relapsing  fever.  Trompetter5  found  it  in 
21  out  of  325  cases,  or  six  per  cent.  There  was  inflammation 
of  the  choroid  and  ciliary  body  with  hypopyon,  but  without 
iritis.  There  were  also  opacities  in  the  vitreous,  amblyopia, 
and  limitation  of  the  field.  Its  origin  is  doubtful.  Throm- 

1  '  Ophthalmologie,"  Bd.  ii.  Abt.  I.  1855,  p.  662. 

2  'Monatsbl.  fur  Augenheilk.,"  Aug.  1865. 

3  'Traite  Iconographique, "  p.  188. 

4  '  Ophth.  Rev.,"  i.  p.  403. 

5  'Klin.  Monatsbl.,"  April,  1880,  p.  123. 


282  MEDICAL   OPHTHALMOSCOPY. 

bosis  in  vessels  or  embolism  from  the  spleen  has  been  assumed 
as  its  cause  (Blessig,  quoted  by  Trompetter). 


MEASLES. 

Amblyopia,  without  ophthalmoscopic  changes  and  ulti- 
mately improving  to  the  normal,  has  been  seen,  as  a  sequel 
to  measles,  by  v.  Graef e  and  Xagel ;  in  some  cases  accom- 
panied by  cerebral  symptoms,  convulsions,  and  sopor.  Nagel 
has  also  met  with  three  cases  of  optic  neuritis  after  measles, 
but  in  the  epidemic  in  which  they  occurred  there  were  many 
cases  of  meningitis.  In  three  other  cases  lately  recorded 
by  Wadsworth l  there  were  also  symptoms  of  meningitis. 
Dr.  Stephenson  2  has  recently  reported  a  well-marked  case  of 
optic  neuritis  after  measles,  without  any  symptoms  indicative 
of  meningitis.  The  observation  is  valuable,  since  the  eyes 
were  examined  shortly  before  the  attack,  and  the  f undi  found 
normal.  The  discs  have  become  paler  than  formerly,  Dr. 
Stephenson  writes,  but  are  not  completely  atrophied,  and 
there  is  still  good  vision.  As  Forster  remarks,  the  common- 
ness of  the  disease,  and  the  rarity  of  affections  of  sight  in  it, 
show  that  the  connection  between  the  two  cannot  be  a  very 
close  one. 

SCARLET  FEVER. 

The  frequency  with  which  renal  disease  accompanies  and 
succeeds  scarlet  fever  renders  affections  of  sight  not  very 
rare  consequences  of  the  disease.  Occasionally,  however, 
they  arise  independently  of  any  renal  disturbance. 

UraBmic  amaurosis  is  common  in  scarlatinal  dropsy.  It 
comes  on  suddenly,  when  the  renal  disease  is  at  its  height,  is 
commonly  complete,  double,  unattended  by  ophthalmoscopic 
changes,  and  passes  away.  Occasionally,  cerebral  symptoms 
accompany  it — convulsions,  and,  in  rare  cases,  hemiplegia, 
from  a  cerebral  thrombosis  or  embolism,  which  persists 
after  the  cessation  of  the  convulsions,  and  the  return  of 
sight. 

1  "  Boston  Med.  and  Surg.  Journal,"  vol.  ciii.  p.  636. 

2  "Trans.  Ophth.  Soc.,"  vol.  viii.  1888,  p.  250. 


SCARLET    FEVER.  283 

Neuro-retinitis  has,  however,  been  observed  to  succeed 
scarlet  fever  when  there  has  been  no  renal  disease  or  albumen 
in  the  urine.  Betke1  has  recorded  a  case  in  which  there  was 
great  dimness  of  sight  seventeen  days  after  desquamation. 
There  was  no  albuminuria,  but  a  marked  neuro-retinitis  was 
found  on  ophthalmoscopic  examination,  less  developed  in  the 
right  eye  than  in  the  left.  There  was  no  sign  of  meningitis, 
past  or  present.  The  neuritis  entirely  disappeared,  and  sight 
was  restored  in  eight  weeks.  A  similar  case  has  been 
recorded  by  Pfluger.2  A  child,  ten  years  old,  became  blind 
three  weeks  after  an  attack  of  scarlet  fever,  the  loss  of  sight 
being  complete  at  the  end  of  three  or  four  days.  During 
the  fever  there  had  been  considerable  headache.  When  sight 
was  lost,  double  papillo-retinitis  was  found  to  exist.  The 
arteries  were  narrow  and  tortuous,  with  slight  pulsation  ; 
the  veins  were  dilated ;  there  was  considerable  swelling,  and 
some  haemorrhages  existed.  A  month  later  sight  had  much 
improved,  but  four  months  after  it  was  not  quite  normal,  and 
the  neuritis  had  not  entirely  subsided.  The  urine  through- 
out was  free  from  albumen.  In  a  case  recorded  by  Hodges3 
the  loss  of  vision  was  due  to  embolism  or  thrombosis  of  one 
retinal  artery.  The  amaurosis  was  complete  and  permanent 
in  the  affected  eye. 

It  is  not  uncommon  to  meet  with  atrophy  of  the  optic  nerve 
after  scarlet  fever,  and  the  atrophy  may  have  all  the  aspects 
of  a  consecutive  atrophy.  It  has  been  observed  in  association 
with  the  symptoms  of  a  local  cerebral  lesion,  hemiplegia,  &c. 
(Loet) ,  but  in  some  cases  has  occurred  alone.  Two  remarkable 
cases  have  been  recorded  by  Bayley,4  in  which,  in  two  sisters, 
sight  gradually  failed  some  months  after  an  attack  of  scarlet 
fever,  without  albuminuria  or  dropsy.  One  became  blind 
and  idiotic,  and  the  other  epileptic.  The  tint  of  the  optic 
discs  was  "  pale  but  not  the  bluish- white  of  atrophy,"  and 
the  fundus  in  each  case  showed  accumulation  of  pigment. 

1  "MoDatsbl.  fur  Augenheilkunde,"  Bd.  viii.  1869,  p.  201. 

2  "  Arch.  f.  Ophth.,"  xxiv.,  pt.  2,  p.  180. 

3  c' Ophth.  Rev.,"  iv.  p.  296. 

4  "Lancet,"  Sept.  15,  1877. 


284  MEDICAL   OPHTHALMOSCOPY. 

It  must  be  remembered  that  an  intense  albuimnuric 
inflammation  may  leave  partial  atrophy  of  the  optic  nerve. 

YARIOLA. 

Leber  has  observed  diffuse  neuro-retinitis  in  variola  during 
the  stage  of  drying  of  the  eruption.  In  a  case  which  came 
under  my  own  observation,  atrophy  of  one  optic  nerve 
appeared  to  have  succeeded  small-pox.  (See  Case  60  in 
previous  editions.) 

ACUTE  RHEUMATISM. 

Acute  rheumatism  is  not  usually  associated  with  any 
changes  in  the  fundus  oculi.  Embolism  of  the  cerebral 
arteries  sometimes,  though  rarely,  occurs  during  the  course 
of  an  attack,  but  embolism  of  the  retinal  arteries  has  not,  I 
believe,  been  observed  except  as  a  late  sequel  of  the  resulting 
endocarditis.  Schmidt  once  observed  irido-choroiditis  (such 
as  is  common  in  relapsing  fever)  after  an  attack  of  acute 
articular  rheumatism  without  endocardial  complication.1 

MALARIAL  FEVERS. 

Changes  in  the  fundus  oculi  are  present  in  some  cases  of 
malarial  fever;  rarely  in  the  intermittent  of  this  country, 
but  not  uncommonly  in  the  severer  forms  of  malarial  fever, 
especially  in  tropical  climates.  Poncet,2  for  instance,  found 
changes  in  ten  per  cent,  of  the  cases  of  malarial  cachexia 
in  Algeria.  The  changes  which  have  been  observed  consist 
of  retinal  haemorrhages,  neuro-retinitis,  and  atrophy  of  the 
optic  nerve. 

Haemorrhages  may  occur  without  other  change,  sometimes 
in  the  posterior  segment  of  the  eyeball,  sometimes  chiefly 
in  the  ciliary  region  (Poncet).  Three  instances  of  retinal 
haemorrhages  in  ague  have  been  recorded  by  Stephen 
Mackenzie.3  One  was  a  young  man,  aged  twenty,  who  had 

1  "Arch.  f.  Ophth.,"  Bd.  xviii. 

2  "Ann.  d'Oculistique,"  May,  1878. 

3  In  a  paper  on  "  Retinal   Haemorrhages   and  Melaiiaemia   as  Symptoms 
of  Ague,"    "Med.  Times  and  Gaz.,"  1877.     I  am  much  indebted  to  Dr 
Mackenzie  for  the  woodcuts  from  his  paper. 


MALARIAL    FEVERS. 


285 


one  attack  of  ague  on  his  way  home  from  India,  and  a  severe 
paroxysm  immediately  after  his  arrival.  The  attacks  recurred 
daily  for  a  fortnight,  when  he  came  under  treatment,  and 
numerous  retinal  haemorrhages  were  found,  most  numerous 
near  the  disc,  chiefly  along  the  course  of  the  larger  vessels, 
especially  arteries,  which  they  in  places  obscured  (Fig.  80). 
Sprinkled  about  the  fundus,  and  most  numerous  near  the 
disc,  were  many  small  round  bright  spots,  resembling  pin- 
holes  pricked  in  a  piece  of  paper  held  up  against  the  light. 


FIG.  80. — RETINAL  HEMORRHAGES  IN  AGUE  (MACKENZIE). 

The  retinal  vessels  were  of  normal  size,  and  their  sheaths  did 
not  appear  thickened.  These  haemorrhages  were  carefully 
observed  day  by  day,  and  were  seen  to  fade  away  gradually ; 
and,  as  each  died  away,  it  left,  to  mark  its  former  situation, 
one  of  the  shiny  white  spots  of  which  mention  has  been 
made  above.  There  was  no  albuminuria  or  other  symptom 
of  Bright's  disease.  The  spleen  was  large.  The  blood  at 
first  contained  much  pigment,  but  after  the  first  few  days  no 
more  could  be  found. 


286 


MEDICAL    OPHTHALMOSCOPY. 


In  two  cases,  at  the  Seamen's  Hospital — a  man,  aged 
twenty-nine,  with  quotidian  ague,  and  another,  aged  eighteen, 
with  tertian  ague — haemorrhages  were  found  ;  in  the  former 
case,  numerous,  large,  and  superficial,  leaving  white  patches. 
One  was  paler  in  the  centre  than  in  the  periphery  (Fig.  81). 
They  quickly  disappeared.  Neither  of  these  patients  had 
melansemia.  In  several  cases  subsequently  examined,  no 
haemorrhages  were  found. 

Hsemorrhagic  retinitis  has  also  been  met  with   by  von 


FIG.  81. — RETINAL  HEMORRHAGES  IN  AGUE  (MACKENZIE). 

Kries.1  One  patient,  who  had  suffered  from  ague  for  a  week 
only,  had  an  extensive  haemorrhage  into  the  vitreous.  The 
intermission  had  been  arrested  by  quinine,  and  the  first 
freedom  on  the  day  of  periodical  recurrence  was  accompanied 
by  the  haemorrhage. 

Poncet  observed,  in  Algeria,  besides  haemorrhages,  peri- 
papillary  oedema  and  even  considerable  neuro-retinitis.  He 
also  found,  in  the  retinal  and  choroidal  vessels,  large  cells 

Arch,  f.  Ophth.,"  vol.  xxiv.  pt.  1,  p.  159. 


MALARIAL    FEVERS.  287 

containing  leucocytes  and  pigment.  Neuritis  has  also  been 
seen  in  one  case  by  Gralezowski,1  and  in  two  by  HammoDd,'2 
unilateral,  with  stellate  deposits  of  pigment  in  the  retina 
following  the  course  of  the  vessels. 

Atrophy  of  the  optic  nerve  has  also  been  observed  to 
succeed  malarial  fever.  It  is  very  rare,  however,  as  a 
consequence  of  the  intermittents  of  temperate  climates, 
although  a  few  cases  are  on  record.  After  the  severe 
malarial  fever  of  hot  climates  it  is  not  infrequent.  Several 
cases  are  narrated  by  Gralezowski  3  and  by  Bull.4  The  disc  is 
white,  the  vessels  are  small,  and  the  field  of  vision  is  greatly 
restricted.  The  pathology  of  the  retinal  changes  is  still 
obscure.  The  retinal  haemorrhages  have  been  ascribed  to 
pigmentary  embolism,  but  they  are,  as  Mackenzie  has  shown, 
to  be  found  when  there  is  no  melansemia.  Poncet  attributes 
them  to  the  blockade  of  minute  vessels  by  leucocytes.  The 
atrophy  was  ascribed  by  Gralezowski  to  pigmentary  embolism. 
It  seems  possible  that  the  atrophy  may  be  the  result  of  such 
neuro-retinitis  as  is  described  above,  and  which,  damaging 
sight  only  during  the  stage  of  atrophy,  attracted  no  attention 
during  its  acute  stage. 

Two  remarkable  cases  which  have  been  recorded  by 
Eamorius,5  suggest  that  spasm  of  the  retinal  vessels  may  be 
a  consequence  of  malarial  poisoning.  The  chief  symptom 
was  periodical  amblyopia,  and  during  one  of  the  attacks  the 
optic  discs  were  pale,  the  retinal  arteries  were  filiform  and 
almost  bloodless,  and  the  veins  were  scarcely  perceptible. 
At  the  same  time  there  was  great  congestion  of  the  face  and 
ears,  and  a  sensation  of  heaviness  in  the  head.  Each  attack 
was  attended  with  a  sensation  of  coloured  circles  moving 
from  the  periphery  of  the  field  towards  the  centre.  In  the 
intervals  between  the  paroxysms  the  appearance  of  the  fundus 
oculi  was  normal.  Bromide  of  potassium  had  no  effect,  but 
quinine  quickly  cured  each  case. 

i  "  Traite  Iconographique,"  p.  190. 

•2  "Trans.  American  Neurological  Society,"  1875.  3  Loc.  cit. 

4  "American  Journ.  of  Med.  Science,"  1877,  p.  403. 

5  "Annali  di  Ottalmologia, "  1877,  pt   1,    and    "Ann.    d'Oculist,"  vol. 
Ixxxii.  p.  200. 


MEDICAL    OPHTHALMOSCOPY. 

Purulent  affections  of  the  eye  (choroiditis,1  iritis,  &c.)  such 
as  are  seen  in  pyaemia,  have  been  described  in  intermittent 
fever,  but  are  extremely  rare,  and  some  doubt  may  be  felt 
regarding  the  diagnosis  of  the  original  disease  when  it  is 
remembered  how  closely  some  cases  of  pyaemia  simulate 
intermittent  fever.  Even  the  influence  of  quinine,  on  which 
diagnostic  weight  is  often  laid,  is  not  entirely  conclusive.2 

ERYSIPELAS. 

Erysipelas  of  the  face  is  sometimes  followed  by  loss  of  sight 
and  by  the  signs  of  atrophy  of  the  optic  nerve  (v.  Grraefe, 
H.  Pagenstecher,  Hutchinson,  and  others).  It  is  produced 
by  the  extension  of  the  cellulitis  into  the  orbit,  and  the 
resulting  damage  to  the  trunk  of  the  optic  nerve  by  invasion 
or  pressure.  V.  Grraefe  has  pointed  out  that  there  is  com- 
monly some  exophthalmos,  but  this  may  be  very  slight, 
and  may  bear  no  proportion  to  the  subsequent  damage  to 
sight.  In  most  recorded  cases  any  symptoms  suggestive 
of  orbital  cellulitis  have  escaped  notice,  probably  from  the 
difficulty  of  the  examination.  In  one,  however  (that  of 
Story3),  there  was  permanent  limitation  of  the  ocular 
movements.  The  loss  of  sight  often  comes  on  rapidly.  In 
one  of  Pagenstecher's  cases  amaurosis  was  complete  at  the 
end  of  fourteen  days.  Early  observations  of  neuritis  or 
neuro-retinitis  have  been  recorded  by  Vossius  and  Lubinski,4 
and  slight  opacity  of  the  retina  has  been  seen  by  many 
observers.  It  rapidly  passed  into  atrophy.  Usually,  how- 
ever, as  soon  as  the  examination  could  be  made,  there  has 
been  pallor  of  the  disc  and  remarkable  narrowing  of  the 
vessels,  the  arteries  especially.  Jager  has  recorded,  for 
instance,  a  case  in  which  an  adhesion  of  the  eyelids 

1  Peunoff :  "CentralbL  fur  Augenk.,"  1879,  p.  120. 

2  For  example,  in  a  case  of  this  kind  described  by  Landesberg,  in  which, 
although   quinine    cut    short   the  affection,    abscesses   formed  during  con- 
valescence, in  one  toe  and  the  forearm. 

3  "Brit.  Med.  Journal,"  March  16,  1878. 

4  Lubinski :   "  Klin.  Monatsbl.,"  April,   1878,   p.  168  ;  Pfliiger  of  Berne  : 
' '  Augenklinik  Bericht"  for  1877;  and  Yirchow's   "  Jahresbericht,"    1878, 
vol.  ii.  p.  438. 


DIPHTHERIA.  289 

required  division  with  the  knife  five  weeks  after  the  ery- 
sipelas ;  the  optic  disc  was  grey  and  atrophied ;  one  branch 
of  the  central  artery  and  its  corresponding  vein  were  normal, 
the  others  reduced  to  lines  with  white  borders.  In  Story's 
case  some  arteries  were  bloodless,  and  occluded  veins  were 
represented  by  dark  radiating  lines. 

It  is  probable  that  thrombosis  in  the  central  artery  is  not 
infrequently  the  mechanism  by  which  the  effect  is  produced. 
Thus,  August1  found  the  ophthalmoscopic  appearances  similar 
to  those  in  embolism  (arteries  either  invisible,  or,  in  places, 
transformed  into  white  lines),  in  a  case  in  which  the  erysipelas 
caused  orbital  cellulitis,  and  in  addition  visible  clotting  in 
supra-orbital  and  frontal  vessels ;  he  believes  that  the  organism 
penetrates  the  walls  and  causes  inflammation  and  clotting. 
Knapp,2  however,  urges  that  the  mechanism  is  compression 
of  vessels  in  the  orbit.  In  an  early  case  he  found  the  veins 
distended  with  stagnant  blood.  He  quotes  Panas,  who  found 
obliteration  of  the  retinal  artery.  In  a  case  observed  by 
Nettleship,  although  the  arteries  were  small  they  pulsated 
on  pressure.  It  seems  to  me  probable  that  the  mechanism  in 
these  cases  is  not  always  the  same. 

In  one  of  Pagenstecher's  cases  there  was  a  central  scotoma 
and  also  peripheral  limitation  of  the  field.  Necrosis  of  the 
nerve,  less  complete  at  the  lamina  cribrosa  than  farther  back, 
was  found  by  Nettleship.3  Opacity  of  the  vitreous  and 
glaucoma  have  also  been  seen  after  erysipelas. 

DIPHTHERIA. 

The  defect  of  sight  which  so  often  follows  diphtheria,  and 
is  due  to  a  paralysis  of  accommodation,  is  not  attended  with 
any  ophthalmoscopic  change.  In  rare  cases,  however,  vision 
is  defective,  apart  from  the  paralysis  of  accommodation,  and 
in  such  cases  one  or  two  observers  (e.g.  Bouchut)  have  found 
congestion  of  the  disc,  simple  or  with  oedema  sufficient  to 
veil  the  edges  and  even,  in  part,  the  vessels,  and  in  very  rare 

1  "  Klin.  Monatsbl.,"  1884,  43. 

2  "Arch.  f.  Augenkr.,"  1884,  i.  83. 

s  "Trans.  Path.  Soc.,"  vol.  xxxi.  1880,  p.  254. 


290  MEDICAL    OPHTHALMOSCOPY. 

cases  an  actual  neuritis  which  may  go  on  to  atrophy.  The 
atrophy  may  be  unilateral,  as  in  one  case  figured  by  Bouchut. 
This  case,  however,  was  accompanied  with  partial  right 
hemiplegia  and  defect  of  speech.  The  congestion  and  oedema 
are .  usually  bilateral,  but  may  be  more  intense  on  one  side 
than  on  the  other.  I  have  also  seen  one  definite  case  of 
primary  atrophy  after  diphtheria.  The  patient  was  a  woman, 
aged  forty-one,  with  a  family  history  of  epilepsy.  Shortly  after 
the  diphtheria  she  suffered  from  numbness  of  the  arms,  from 
paralysis  of  the  palate  and  of  accommodation,  and  from  double 
vision.  With  the  exception  of  the  diplopia  these  symptoms 
passed  off ;  but,  a  little  later,  slight  weakness  of  the  right 
side  developed  and  became  permanent.  Along  with  this 
there  occurred  progressive  failure  of  sight,  and  two  years  later 
there  was  well-marked  primary  atrophy  of  the  optic  nerves, 
with  considerable  amblyopia.  The  pupils  did  not  react  to 
light  in  the  least,  and  but  slightly  to  accommodation.  There 
was  nystagmus  on  looking  to  the  left,  and  the  upward 
movement  of  the  eyes  was  completely  lost.  There  were 
no  other  signs  of  tabes,  and  the  knee-jerks  were  perfect. 

PAROTITIS. 

Transient  dimness  of  sight  may  succeed  mumps,  and  a 
coincident  congestion  of  the  optic  nerve  has  been  described 
by  Hating. 

TONSILLITIS. 

In  a  case  of  tonsillitis  v.  Graefe  once  saw  signs  of  diminished 
blood-supply  to  the  retina  accompanying  sudden  loss  of  sight. 
The  known  relation  of  tonsillitis  to  rheumatism  suggests  the 
probability  of  embolism  in  this  singular  case. 

WHOOPING-COUGH. 

Blindness  has  been  observed  to  come  on  during  the  progress 
of  whooping-cough,  and  in  one  case  Knapp1  found  the  discs 
white,  and  the  retinal  arteries  invisible  in  one  eye  and  mere 

i  "Arch,  of  Ophthalm.  and  Otol.,"  vol.  iv.  Xos.  3  and  4,  p.  448. 


PYJEMIA    AND    SEPTICAEMIA.  291 

lines  in  the  other.  The  patient  was  very  weak,  and  Knapp 
suggests  as  explanations,  anaemia  from  cardiac  weakness, 
or  haemorrhage  into  the  nerve-sheaths.  Landesberg1  also 
observed  in  one  case  symptoms  of  partial  embolism,  serous 
infiltration  into  the  retina,  slight  swelling  of  the  papilla, 
a  red  macula,  thin  arteries,  engorged  and  tortuous  veins. 
Two  upper  arterial  branches  were  found  to  be  permanently 
obstructed.  In  another  case  he  observed  ecchymoses  in 
the  retina.  According  to  Loomis  (quoted  by  Knapp),  loss 
of  sight  generally  occurs,  in  this  disease,  in  children  who 
are  much  prostrated,  and  who  commonly  die  from  lobular 
pneumonia. 

CHOLERA. 

In  cholera  v.  Grraef  e  found  that,  during  the  state  of  collapse 
and  cyanosis,  the  circulation  in  the  smaller,  and  even  in  the 
middle-sized,  arteries  may  apparently  cease.  When  the 
weakness  of  the  heart  was  moderate,  the  artery  pulsated  on 
slight  pressure  with  the  finger  on  the  eyeball ;  but  when  the 
heart  was  strong  this  could  not  be  well  produced.  If  the 
heart  was  so  weak  that  the  radial  pulse  could  not  be  felt,  and 
the  second  sound  of  the  heart  was  inaudible,  slight  pressure 
on  the  eye  caused  emptying  of  the  arteries  without  pulsation. 
The  veins  were  large  and  dark,  visible  in  the  finest  divisions. 
The  papilla  was  of  a  pale  lilac  tint. 

PYJEMIA  AND  SEPTICAEMIA. 

The  occurrence  of  a  general  inflammation  of  the  eye  in 
cases  of  septicaemia  of  various  kinds,  "  metastatic  panophthal- 
mitis,"  has  long  been  known,  but  it  is  only  during  the  last 
few  years  that  the  use  of  the  ophthalmoscope  in  medical  and 
surgical  practice  has  revealed  the  fact  that  slighter  retinal 
changes  are  present  in  a  large  proportion  of  the  severer  forms 
of  these  affections,  and  constitute  a  symptom  of  considerable 
diagnostic  and  prognostic  importance,  as  well  as  of  great 
pathological  interest.  The  knowledge  of  their  character  is 

1  "Med.  and  Surg.  Reporter,"  Sept.  8,  1880. 


292  MEDICAL    OPHTHALMOSCOPY. 

largely  due  to  the  labours  of  Heiberg,1  Both,2  and  especially 
of  Litten.3  All  forms  of  affection  are  most  common  in  the 
intense  septicaemia  of  puerperal  women,  but  are  also  met 
with  in  other  cases. 

Panophthalmitis. — The  general  inflammation  of  the  eye, 
"  pysemic  or  metastatic  ophthalmia,"  is  usually  attended  with 
suppuration  in  the  various  structures — iris,  ohoroid,  retina, 
vitreous — with  rapid  destruction  of  the  eyeball.  It  was 
shown  by  Virchow4  to  depend  upon  septic  embolism,  and  later 
researches  have  fully  confirmed  the  fact.  Plugs  in  the  vessels 
have  been  found  by  Virchow,  Eoth,  and  Heiberg.  The  latter 
found  micrococci  in  the  emboli.  It  is  usually  associated  with 
the  endocarditis  which  is  so  common  in  septicaemia.  Virchow 
found  yellowish  granular  masses  in  the  capillaries  of  the 
retina,  similar  to  those  which  were  present  in  the  cardiac 
valves,  and  he,  with  most  subsequent  observers,  regarded  the 
cardiac  valves  as  the  source  of  the  emboli.  The  condition  may, 
however,  occur  independently  of  any  endocarditis.5  Even  in 
such  cases,  however,  the  presence  of  infarcts  in  other  organs, 
and  of  suppurating  thrombi  in  the  source  of  the  septicaemia, 
demonstrated  the  probability  of  embolism,  although  not 
directly  from  the  heart.  It  is  well  known  that  pyaemic 
emboli  may  pass  through  the  lungs  and  lodge  in  the  general 
system.  The  septic  inflammation  excited  in  the  eye  may 
start  from  the  choroid  or  the  retina,  as  is  demonstrated  by 
two  cases  of  Litten's,  in  which  the  process  commenced  a 
short  time  before  death,  and  he  found  plugging  in  the  one 
case  of  choroidal  and  in  the  other  of  retinal  vessels.  A  case 
in  which  the  mischief  apparently  commenced  in  the  retina 
has  also  been  described  by  Eoth.  When  the  retinal  vessels 
are  plugged,  haemorrhages  in  the  retina  are  invariable,  as 
Virchow  demonstrated,  and  the  commencement  of  the  process 

i  "Med.  Centralblatt,"  1874,  No.  36. 

a"Deut.  Zeitschrift  fur  Chirurgie,"  1872,  p.  471;  Nagel's  "Jahres- 
bericht,"  1872,  p.  349. 

3  "Charite  Annalen  "  for  1876,  p.  160. 

4  "Arch.  f.  Path.  Anat.,"  Bd.  x.  1856. 

5  Litten:  loc.  cit.  Case  8  ;  Meckel :   "  Charite  Annalen,"  Bd.  v. ;  Virchow: 
"Ges.  Abhand.,"  p.  539  ;  Schmidt:  "Arch.  f.  Ophth.,"  xviii.  p.  1. 


PIVEMIA    AND    SEPTiC^MIA.  293 

in  retinal  haemorrhages,  with  opacity  of  the  retina  and 
vitreous,  may  be  watched  with  the  ophthalmoscope.1  The 
opacity  of  the  retina  depends  apparently  in  most  cases  on 
acute  degeneration.  It  was  found  by  Both  to  be  merely 
softened,  and  containing  granule  cells,  although  the  other 
structures  of  the  eye  were  infiltrated  with  pus.  A  layer  of 
pus  has,  however,  been  seen  on  the  surface  of  the  retina,  and 
pus  is  said  to  have  been  found  in  some  cases  in  the  nerve- 
fibre  layer.  Rarely,  the  changes  have  been  found  limited  to 
a  small  area  of  the  retina  and  the  adjacent  choroid. 

It  is  probable  that  this  severe  ocular  inflammation  is 
always  produced  by  the  agency  of  septic  organisms  circula- 
ting in  the  blood.  These,  in  the  form  of  bacterial  or 
micrococcal  masses,  have  been  found  in  the  vessels  of  the  eye 
in  many  cases.2 

The  affection  is  usually  single,  but  in  many  cases  both 
eyes  are  affected,  it  may  be  unequally.  It  occurs  only  in 
intense  forms  of  septicaemia,  commonly  not  long  before  death. 
In  rare  cases  it  may  occur  when  the  general  symptoms  of  the 
disease  are  hot  advanced,  as  in  a  case  mentioned  by  Litten, 
in  which  a  woman  came  to  the  hospital  with  one  eye  in  a 
state  of  complete  suppuration,  but  with  so  little  subjective 
symptom  of  the  considerable  fever  which  was  found  to  exist, 
that  she  was  unwilling  to  remain.  Death  occurred  some 
weeks  after  the  eye  was  lost.  Ophthalmoscopic  examination 
of  the  sound  eye  revealed  no  change  for  some  time  after 
admission.  One  day  choroiditis  and  infiltration  of  the 
vitreous  was  discovered ;  the  same  day  rigors  and  joint- 
inflammation  occurred,  and  in  three  days  later  the  patient 
was  dead. 

Retinitis  Septica. — Roth  has  described  a  peculiar  form  of 
retinitis  in  cases  of  pyaemia,  characterized  by  the  appearance 
of  small  white  flecks  in  the  neighbourhood  of  the  papilla  and 
macula  lutea,  varying  in  number,  and  occurring  in  most 

1  Litten  :  Case  8. 

"Kahler:  "Prag.  Zeitsch.  f.  Heilkunde,"  1879,  iii.,  and  "Centralbl.  f. 
Med.  Wiss.,"  1880,  p.  728;  Pousson  :  "Arch.  d'Ophth.  Fran^aise,"  No.  2, 
Jan.  1881  ;  Hosch :  "Arch.  f.  Opkth.,"  vol.  xxvi.  pt.  i,  p.  177. 


294  MEDICAL    OPHTHALMOSCOPY. 

cases  in  both  eyes.  Sometimes  small  haemorrhages  were 
present.  The  white  spots  were  found  to  consist  of  groups  of 
swollen  nerve-fibres,  among  which  were  granule  cells,  fattily- 
degenerated  capillaries,  and  pigment  granules.  The  affected 
spots  were  of  small  size,  and  showed  little  tendency  to 
extension,  or  to  the  involvement  of  the  vitreous  or  choroid. 
In  no  case  observed  by  Both  was  any  plugging  of  vessels 
discovered,  or  any  deposits  on  the  cardiac  valves,  and  he 
therefore  believes  that  the  change  is  due  to  the  chemical 
alteration  of  the  blood,  but  Kahler  found  micrococcal  plugs. 
The  affection  was  met  with  especially  in  cases  in  which 
decomposition  was  occurring  in  inflamed  parts,  such  as  exten- 
sive sloughing  with  secondary  suppuration,  and  especially  in 
pronounced  septicaemia.  It  was  found  also  in  one  case 
of  putrid  bronchitis. 

Retinal  hcemorrhayes  constitute,  however,  by  far  the  most 
common  and  most  important  change  in  the  f  undus  in  cases  of 
septicaemia.  They  usually  accompany  the  suppurative  panoph- 
thalmitis,  especially  when  the  process  commences  in  the  retina. 
They  may  also  occur  in  the  form  described  by  Roth.  But 
they  may  exist  alone,  without  any  sign  of  retinal  inflamma- 
tion, and  as  such  constitute  the  most  common  ophthalmoscopic 
change  in  these  cases.  They  have  been  very  carefully  studied 
by  Litten,  in  cases  of  puerperal  septicaemia,  in  which  they 
almost  invariably  occur  during  the  last  two  or  three  days  of 
life.  They  are  always  bilateral,  round,  or  irregular  in  form, 
and  of  variable  size,  sometimes  very  large.  They  are  com- 
monly adjacent  to  vessels,  especially  veins,  but  occasionally 
are  situated  apart  from  visible  vessels.  Most  of  the  round 
extravasations  present  pale  or  white  centres,  which  are  often 
distinct  as  soon  as  the  haemorrhage  appears.  They  are  recog- 
nized without  difficulty,  some  being  always  in  the  posterior 
portion  of  the  fundus. 

In  some  of  the  cases  in  which  these  haemorrhages  were  seen, 
there  was  endocarditis,  but  in  several  cases  recorded  by  Both 
and  Litten  the  heart  was  healthy.  There  is  thus  no  necessary 
connection  between  the  cardiac  and  the  ocular  condition. 
Moreover,  the  retinal  change  appears  comparatively  innocent ; 


PYJEMIA    AND    SEPTICAEMIA.  295 

no  adjacent  inflammation  is  excited.  In  no  case  could  Litten 
find  any  plugging  of  the  retinal  vessels,  and  from  these 
facts,  he  concludes  with  Both,  that  embolism  is  not  the  cause 
of  these  extravasations,  but  that  they  are  to  be  ascribed  to 
the  chemical  change  in  the  blood.  This  view  is  also  supported 
by  a  case  described  by  Leube,1  but  the  same  observer  has 
recorded  another  case  of  septic  pyaemia,  secondary  to 


Y 


FIG.  82. — RETINAL  HAEMORRHAGES  IN  A  CASE  OF  ACTTDB  ULCERATIVE 
ENDOCARDITIS. 

Some  are  striated  in  the  nerve-fibre  layer,  others  rounded  in  the  deeper  layers 
many  have  white  spots  in  the  centre. 

double  caseating  epididymitis,  in  which  retinal  haemorrhages 
existed,  and,  post-mortem,  bacterial  plugs  were  found  in  many 
other  organs.  The  retinae  apparently  were  not  examined. 
Rosenbach,2  however,  found  a  similar  condition  of  multiple 
haemorrhages  in  the  retinae  of  dogs,  in  which  a  septic 
endocarditis  had  resulted  from  experimental  lesions  of  the 
valves,  and  he  found  micrococcal  plugs  in  the  retinal  vessels 

1  "Deut.  Arch,  fur  Klin.  Med.,"  xxii.  1878,  p.  235. 

2  "Arch,  fur  Exp.  Path,  und  Pharmak.,"  1878. 


296 


MEDICAL    OPHTHALMOSCOPY. 


after  death.  From  these  facts  we  may  conclude  that, 
although  simple  haemorrhages  usually  arise  independently  of 
embolism,  they  may  sometimes  he  due  to  the  plugging  of 
vessels.  In  connection  with  the  remark,  that  adjacent  in- 
flammation is  often  not  excited,  it  may  be  noted  that  of  six 
cases  with  endocarditis  observed  by  Litten,  in  only  three  did 
the  cardiac  change  present  the  aspect  of  malignant  ulcerating 
endocarditis ;  in  the  other  three  the  valves  presented  only 
innocent-looking  vegetations.  It  is  probable  that  the  endo- 
carditis varies  in  its  degree  of  septic  character  in  different 


FIG.  83. — RETINAL  HJEMOKKHAGES  IN  A  CASE  or  ACUTE  ULCEKATIVE 
ENDOCARDITIS  AND  CHOIIEA. 

The  rounded  hemorrhage  at  the  lower  part  of  the  figure  has  a  white  centre. 

cases  of  blood  poisoning.  In  several  cases  of  pyaemia  similar 
haemorrhages  have  been  noted  on  the  mucous  membrane  of 
the  conjunctiva  or  mouth  (Litten,  Leube). 

From  the  fact  that  the  retinal  haemorrhages  usually  pre- 
cede death  by  a  few  days  only,  they  afford  important  and 
very  grave  prognostic  information.  Now  and  then  they  are 
useful  also  in  diagnosis,  since  they  are  apparently  not  found 
in  acute  specific  diseases,  even  in  those  severe  cases  in  which 
cutaneous  haemorrhages  are  present.  Litten  mentions  two 


THE    OPHTHALMOSCOPIC    SIGNS    OF    DEATH.  297 

cases  of  women  admitted  with  high  fever,  cutaneous  extrava- 
sations, and  cardiac  murmurs.  One  had  been  recently  con- 
fined. They  had  the  aspect  of  cases  of  septicaemia  rather 
than  of  typhoid,  but  the  absence  of  retinal  extravasations 
led  to  a  diagnosis  of  typhoid  fever,  which,  in  each  case, 
was  confirmed  by  a  post-mortem  examination.  I  have  seen 
one  case  in  which  the  presence  of  retinal  haemorrhages 
was  of  considerable  assistance  in  establishing  the  fact  that 
a  post-puerperal  illness,  supposed  to  be  typhoid,  was  really 
septicaemia. 

The  effect  of  the  retinal  haemorrhages  on  vision  can  rarely 
be  ascertained  with  exactness,  on  account  of  the  general  state 
of  the  patients,  but  they  appear  to  cause  little  impairment. 

Purulent  meningitis  sometimes  occurs  in  cases  of  septi- 
caemia. In  one  such  case,  recorded  by  Leube,1  there  were 
retinal  extravasations,  but  after  death  intense  inflammation 
of  the  optic  nerves  adjacent  to  the  inflamed  membranes  was 
found. 


THE  OPHTHALMOSCOPIC  SIGNS  OF  DEATH. 

The  stoppage  of  the  heart's  action  and  the  consequent 
arrest  of  the  circulation  of  the  blood,  which  constitute  the 
chief  events  in  the  cessation  of  systemic  life,  lead  to  striking 
changes  in  the  fundus  oculi,  changes  which  are  among  the 
most  unequivocal  signs  of  death.  Attention  was  first  called  to 
them  by  Bouchut  in  1863,2  and  they  have  since  been  studied  by 
many  observers,  especially  by  Poncet,3  Arlidge,4  and  Grayet.5 

As  the  heart's  action  is  failing,  the  arteries  may  be  observed 
to  diminish  in  size  (Arlidge).  On  the  cessation  of  its  con- 
tractions, the  diminution  in  their  size  becomes  more  marked. 
A  few  minutes  after  death  the  capillary  redness  of  the  disc 
disappears,  and  its  surface  becomes  of  papery  whiteness,  in 

1  "Deut.  Arch,  fur  Kliii.  Med.,"  Bd.  xxii.  1878,  p.  263. 
•  "  Traite  des  Signes  de  la  Alort,"  1863. 

3  "Arch.  Gen.  de  Med.,"  1870,  p.  408. 

4  "West  Riding  Asylum  Reports/'  i.  1871,  p.  73. 
3  "Ann.  d'Oculistique,"  t.  Ixxiii.  1875,  p.  5. 


298  MEDICAL    OPHTHALMOSCOPY. 

which,  however,  the  central  cup,  if  present,  may  appear  of 
still  more  brilliant  whiteness.  The  arteries  quickly  cease  to 
be  recognizable  upon  the  disc,  appearing  to  commence  at  its 
edge.  On  the  fundus  they  are  at  first  distinct,  and  usually 
narrow  but  otherwise  of  normal  appearance.  The  veins 
may  present  normal  characters,  or  may,  like  the  arteries, 
quickly  become  indistinct  upon  the  disc,  appearing  to  start 
from  its  edge.  Commonly  the  columns  of  blood  within  them 
soon  become  interrupted  and  broken  up  into  segments,  which 
give  the  vessels  a  beaded  appearance.  The  indistinctness  of 
the  arteries,  which  is  due  to  their  contraction  emptying  them 
of  blood,  quickly  extends  towards  the  periphery,  and  in  the 
course  of  half  an  hour,  sometimes  in  ten  minutes,  they  are 
unrecognizable.  The  veins  remain  distinct,  but  in  most  cases 
the  beaded  appearance  increases.  The  choroid,  during  the 
first  few  minutes,  presents  nearly  its  normal  tint,  but  this 
quickly  lessens  in  intensity,  and  the  colour  which  is  pre- 
sented depends  on  the  amount  of  pigmentation.  In  dark 
eyes  it  acquires  a  yellow-brown  colour,  in  lightly  pigmented 
eyes  it  gradually  assumes  a  pale,  reddish-yellowish,  sometimes 
a  greyish,  tint.  Commencing  opacity  of  the  retina  may  some- 
times be  distinguished,  and  may  be  accompanied  by  a  red  spot 
at  the  macula  lutea  (Gayet) ,  due  to  its  freedom  from  opacity, 
and  similar  to  that  seen  in  embolism  of  the  central  artery. 

These  appearances  persist  until,  generally  after  five  or 
six  hours,  the  progressive  opacity  of  the  media  prevents 
further  observation. 


APPENDIX. 


HOW   TO   SKETCH  THE  FUNDUS  OCULI. 

NOTHING  gives  dexterity  in  the  use  of  the  ophthalmoscope 
so  quickly  and  so  effectively  as  an  attempt  to  draw  what  is 
seen,  and  nothing  gives  ability  to  recognize  details  with 
accuracy  and  perceive  every  feature  presented,  as  a  habit  of 
drawing  does.  Yet  ophthalmoscopic  drawing  is  hardly  ever 
practised.  It  is  supposed  to  be  difficult,  but  it  is  neither 
difficult  nor  does  it  need  any  ability  or  facility  for  ordinary 
drawing.  The  process  is  within  the  reach  of  every  student, 
and  it  may  be  well  therefore  to  describe  the  method  which  is 
most  useful.  It  is  indeed  sufficiently  simple  as  scarcely  to 
need  even  descriptive  instruction,  but  it  may  be  well  not  to 
assume  that  it  can  be  discovered  by  each  student  for  himself. 

A  pencil  drawing  should  be  first  made,  and  from  that 
either  a  more  perfect  pencil  drawing  on  any  paper  that  has 
a  grain ;  or,  what  is  better,  a  coloured  drawing,  which  re- 
quires, however,  a  skill  a  pencil  drawing  does  not  need. 

The  disc  should  be  drawn  from  f  inch  to  1  inch  in  vertical 
diameter.  The  fundus  should  be  observed  first  by  the 
indirect  method,  and  the  outline  of  the  disc  made  on  a  piece 
of  paper  by  a  faint  pencil  line,  and  other  simple  pencil  lines 
should  indicate  the  position  of  the  chief  vessels  that  can  be  seen 
by  this  method,  the  veins  being  made  darker  than  the  arteries. 
This  being  done,  the  observer  should  continue  and  complete 
the  drawing  by  the  direct  method.  If  he  is  drawing  the 
patient's  left  eye,  his  pencil  and  materials  should  be  on  a 
small  table  to  his  right ;  if  he  is  drawing  the  patient's  right 


300  APPENDIX. 

eye,  this  may  be  on  his  left  or  immediately  in  front  of  him,  he 
sitting  to  the  side  of  the  patient.  To  continue  the  drawing  he 
must  turn  his  paper  upside  down.  This  brings  the  disc,  as 
drawn  from  the  indirect  image,  into  the  position  in  which  it 
appears  in  the  direct  image.  Both  arteries  and  veins  must 
now  be  represented,  as  they  are  seen,  with  a  double  contour. 
After  indicating  more  precisely  the  position  and  outline  of  the 
physiological  cup,  some  one  large  vein  should  be  selected,  and 
its  position  at  the  edge  of  the  cup  and  edge  of  the  disc  noted, 
compared  with  the  first  drawing,  and,  if  necessary,  corrected. 
Then  its  double  contour  should  be  marked  by  a  broad  pencil 
line  on  each  side,  with  a  very  slight  pencil  tint  between 
them,  where  the  reflection  is  seen.  This  must  be  darkened 
wherever  the  reflection  is  lost  in  consequence  of  the  vein 
being  in  some  other  plane  than  that  at  right  angles  to  the 
line  of  vision,  e.g.,  when  passing  over  some  prominence,  or 
receding  into  the  physiological  cup. 

The  branches  of  this  vein  and  the  artery  accompanying  it 
should  then  be  drawn  in  like  manner,  the  artery  being  repre- 
sented by  paler  pencil  lines  and  its  central  reflection  being 
left  white.  Great  care  must  be  taken  to  depict  accurately 
the  relative  width  of  each  vessel,  both  on  the  surface  of 
the  disc  and  beyond  its  edge.  The  width  of  the  vein  first 
drawn,  must  also  be  compared  with  the  size  of  the  cup 
and  the  disc  generally,  and  this  vein  taken  as  a  standard 
with  which  to  compare  the  others  ;  in  this  manner  the  pre- 
cise representation  of  the  size  of  the  various  vessels — a  very 
important  point — is  much  facilitated.  Each  of  the  other 
vessels  should  then  be  drawn  in  the  same  way ;  as  a  rule, 
each  different  vein  first  and  then  its  artery. 

It  is  necessary  to  indicate  many  features  by  some  arbitrary 
signs,  or  by  reference-indications  to  words  written  on  the 
margin.  Among  the  points  to  which  attention  should  be 
given,  is  the  presence  of  white  lines  along  the  vessels,  due  to 
the  tissue  of  the  wall.  It  will  be  remembered  that,  when 
we  speak  of  the  vessels  we  are  drawing,  we  mean  only  the 
columns  of  blood  within  them ;  we  cannot  see  the  vessels 
themselves  except  in  the  appearance  now  referred  to. 


APPENDIX.  301 

These  white  lines  may  be  indicated  conveniently  by  dotted 
lines  outside  the  darker  ones.  Where  the  vessel  becomes 
indistinct,  there  should  be,  of  course,  a  corresponding  indis- 
tinctness of  the  lines  representing  it ;  but  often  this  is  not 
enough  to  indicate  the  degree  of  concealment,  and  then  lines 
may  be  drawn  across  the  vessel. 

The  shape  of  the  central  cup  should  be  carefully  attended 
to,  as  well  as  its  depth,  and  the  course  of  the  vessels  down  its 
side.  The  latter,  together  with  the  change  in  their  aspect, 
represents  the  steepness  of  the  side,  and  shows  it  at  once 
to  one  who  is  used  to  ophthalmoscopic  examination.  The 
manner  in  which  the  vessels  disappear  at  the  bottom  of  the 
cup  varies,  and  must  be  carefully  indicated  in  the  sketch. 
Often  they  gradually  pass  from  view  as  they  penetrate  the 
tissue,  which  at  length  conceals  them ;  then  they  not  only 
become  fainter  but  also  narrower,  because  at  the  edge  of  the 
column  the  depth  of  blood  is  less  and  its  tint  is  less  deep ; 
hence  the  margin  becomes  first  concealed,  and  the  vessel 
seems  to  lose  in  width  as  it  loses  colour. 

In  normal  discs  it  is  common  to  have  a  little  softening 
of  the  edge  where  the  chief  vessels  cross  above  and  below, 
striated  in  character,  and  due  to  the  large  number  of  nerve- 
fibres  which  cross  the  edge  there.  This  may  be  indicated 
by  faint  lines  across  the  edge. 

In  general  it  is  convenient  to  indicate  all  features  that 
are  white  by  dotted  lines.  Thus  the  outline  of  a  white 
spot  or  patch  should  be  made  with  dots  instead  of  by  a 
continuous  line.  If  there  is  a  difference  in  the  intensity  of 
the  whiteness  in  different  parts  of  the  area,  it  must  be  drawn 
black  with  the  pencil,  the  intensity  of  the  white  tint  being 
inversely  indicated  by  the  intensity  of  the  pencil  shading, 
and  the  fact  that  it  is  white  indicated  by  a  dotted  line 
around  it  (not  then  indicating  the  position  of  the  edge, 
which  should  be  the  edge  of  the  shading),  or  else  by  a 
written  indication  adjacent  to  the  spot  or  in  the  margin. 

So,  too,  the  sclerotic  ring  should  be  shown  by  dotted  lines, 
and  also  the  outline  of  a  posterior  staphyloma.  White  spots 
of  albuminuric  retinitis  may  be  made  dark,  without  the  risk 


APPENDIX. 


of  error,  if  —  as  should  always  be  the  case  —  the  more  finished 
drawing  is  made  without  any  delay  to  permit  the  nature  of 
the  case  being  forgotten.  This  lessens  the  practical  difficulty 
that  we  have  to  contend  with  —  the  difficulty  that  we  have 
only  the  lead  pencil  to  indicate  the  white,  the  black,  the  red, 
and  the  grey.  We  must  indicate  the  grey  in  a  large  cup 
or  on  an  atrophied  disc  as  we  indicate  the  red  tint,  marking 
the  difference  by  words  or  letters  on  the  rough  drawing,  and 
in  a  descriptive  note  on  the  more  finished  one. 

Some  remarks  on  the  production  of  coloured  drawings  may 
be  acceptable  to  those  who  have  no  knowledge  of  water- 
colour  work.  I  offer  the  following  suggestions  because  they 
embody  the  results  of  an  attempt  to  make  such  drawings 
without  any  knowledge  of  the  art. 

Colour  is  necessary  for  a  perfect  representation  of  the 
aspect  of  the  fundus,  but  care  must  be  taken  not  to  lose 
sight  of  form,  even  in  its  minutiae.  The  knowledge  of 
pigments  that  is  requisite  is  best  gained  by  experiment,  and 
it  is  wise  to  obtain  pigments  of  the  proper  tints,  if  possible, 
and  to  mix  as  little  as  possible.  The  "  wash  "  is  the  chief 
thing  that  is  needed,  and  this  is  easily  acquired  with  a  little 
practice.  Details  only  need  patient  care.  Fortunately,  in  the 
features  that  can  only  be  represented  in  colour,  the  exact  shade 
of  colour  is  comparatively  unimportant.  The  precise  tint  of 
the  choroid  varies  so  much,  that  correspondence  with  nature,  so 
far  as  relates  to  the  individual  eye,  is  not  appreciated,  indeed 
is  not  observed  by  most  persons,  and  hence  a  divergence  from 
nature  is  equally  unobserved.  Of  course  the  limits  of  the 
variations  that  are  met  with  in  the  tint  of  the  choroid  must 
not  be  exceeded,  and  in  the  cases  in  which  there  is  a  choroidal 
change  to  be  depicted  the  amount  of  pigment  in  the  choroid 
must  be  carefully  observed. 

The  chief  difficulties  with  the  colour  are  —  to  obtain  a 
natural  appearance  as  regards  texture,  and  to  obtain  even- 
ness of  the  tint.  The  beginner  may  take  comfort  in 
the  fact  that  any  defects  will  be  concealed  to  a  large 
extent  by  details  afterwards  added.  The  conspicuous  forms  of 


APPENDIX.  303 

the  vessels  prevent  even  a  considerable  unevenness  from  being 
noticed.  Professional  artists  use  Bristol  board  for  the  coloured 
drawings,  and  the  surface  of  this,  after  having  been  well  washed, 
is  not  so  bad  as  might  be  imagined.  I  prefer,  myself,  a  thin 
hot-pressed  paper,  damped  and  stretched.  The  grain  thus 
obtained  is  finer  than  that  of  a  paper  which  has  not  been 
hot-pressed,  and  yet  it  takes  the  colour  perfectly  well.  All 
the  sepia  drawings  in  this  work  were  done  upon  such  paper. 
Hollingsworth's  I  found  distinctly  better  than  any  other  I 
tried. 

The  difficulties  with  the  colour  arising  from  these  two 
causes — (1)  getting  the  proper  tint  of  red ;  (2)  putting 
the  colour  evenly  on  the  paper — may  thus  be  overcome  : 
(1)  Do  not  use  vermilion.  Any  colounnan  will  give  you 
a  choice  of  reds  sufficiently  large  to  represent  every  possible 
tint  the  human  blood  can  assume.  A  little  light  red, 
added  to  carmine,  answers  very  well ;  but  if  the  tint  of  any 
drawing  which  seems  near  nature,  is  taken  and  compared 
with  sample  tints,  no  difficulty  will  be  experienced  in 
selecting  one  that  corresponds  sufficiently  closely.  (2)  Even- 
ness of  surface  is  best  obtained  by  washing  the  coat  of 
colour  with  water,  when  it  is  quite  dry,  and  then  placing 
blotting  paper  on  it,  This,  of  course,  takes  off  a  good  deal  of 
colour ;  but  by  laying  on  another  coat  (before  the  surface  is 
quite  dry),  and  repeating  the  process  three  or  four  times,  a  very 
even  tint  is  obtained  without  difficulty.  If  any  inequalities 
are  seen  they  may  be  removed  by  "  stippling  "  with  the 
point  of  a  brush.  Some  professional  artists  get  the  ground 
almost  entirely  in  this  manner,  and  it  was  the  method 
adopted  by  the  late  Mr.  Streatfeild,  who,  in  his  early  days, 
made  admirable  ophthalmoscopic  drawings.  Genera]  stip- 
pling may  be  necessary  when  there  are  peculiarities  of  the 
choroid,  for  the  distribution  of  its  pigment  can  only 
thus  be  represented.  For  neuritis  it  is  not  necessary. 
The  method  of  successive  coats  has  an  advantage  in  the 
softness  of  the  edge  of  an  inflamed  disc  that  can  be 
obtained.  It  is  better  to  take  out,  from  each  wash,  the  area 
of  the  disc,  by  the  end  of  a  small  roll  of  blotting  paper, 


304  APPENDIX. 

than  to  leave  it,  on  account  of  the  hardness  of  the  edge 
which  the  latter  method  involves  (except  in  the  hands  of  a 
skilful  artist,  for  whom  these  directions  are  not  intended). 
By  softening  the  edge  of  the  colour  with  a  wet  brush,  how- 
ever, then  pressing  blotting  paper  firmly  on  it,  and  repeating 
the  process  several  times,  any  part  may  be  made  as  soft  in 
its  gradation  as  can  be  desired.  Sharp-edged,  perfectly 
white  spots  may  be  produced  with  a  penknife. 


PIRATE   I. 


DESCRIPTION     OF     PLATES. 


THE  ophthalmoscopic  illustrations  contained  in  the  following  plates 
are  from  drawings  of  the  erect  image,  with  the  exception  of  PI.  I. 
Figs.  1,  3,  &  o  ;  PL  VI.  Fig.  1,  and  PL  XII.  Fig,  2,  which  are  of  the 
inverted  image.  In  some  of  the  other  figures,  however,  the  draw- 
ings, although  of  the  erect  image  and  made  on  a  large  scale,  have 
been  reduced  in  the  photographic  reproduction  nearly  to  the  dimen- 
sions of  the  inverted  image. 

PLATE   1. 

FIGS.  1  &  2. — Simple  congestion  of  the  optic  disc  in  a  case  of  embolic 
softening  in  right  cerebral  hemisphere,  causing  left  hemiplegia.  Right 
optic  disc  five  weeks  after  onset. 

Man,  aged  thirty,  had  rheumatic  fever  at  thirteen.  The  con- 
gestion of  the  discs  came  on  a  fortnight  or  so  subsequently  to 
the  occurrence  of  hemiplegia,  and  then  remained  unchanged  for 
about  six  weeks.  Both  discs  ultimately  became  much  less  congested, 
the  left  clearing  first.  The  paralysis  remained  absolute,  and  there 
was  rapid  wasting  of  limbs.  Later,  blood  and  albumen  appeared  in 
the  urine,  and  rounded  haemorrhages  with  white  centres  were  found 
over  both  retinae ;  soon  afterwards  distinct  optic  neuritis  developed 
in  the  right  eye  only.  Three  weeks  later  patient  died.  Right  middle 
cerebral  artery  plugged ;  corpus  striatum  softened  throughout ;  traces 
of  slight  old  meningitis  over  both  hemispheres  ;  infarcts  in  spleen  and 
in  kidneys,  the  latter  being  "large  white;"  aortic  and  mitral  disease. 
The  late  retinal  hemorrhages  were  probably  due  to  the  blood-state. 
Note  occurrence  of  neuritis  on  same  side  as  cerebral  lesion. 

FIG.  1  represents  the  disc  as  seen  by  the  indirect  method  of  examination. 
The  tint  is  nearly  that  of  the  adjacent  fundus,  and  is  uniformly  dis- 
tributed over  the  disc.  The  edge  is  dimly  seen  as  a  pale  zone,  most 
distinct  on  the  right  (temporal)  side.  The  veins  are  large,  especially 
one  which  passes  apparently  upwards  (really  downwards).  Several 
small  vessels  passing  from  the  disc  are  unduly  visible. 

FIG.  2. — The  same  disc  as  seen  by  the  direct  method  (upright  image) 

X 


306  MEDICAL   OPHTHALMOSCOPY. 

— reduced.  The  uniform  red  tint  is  as  conspicuous  as  by  the  indirect 
method.  The  sclerotic  ring  is  visible  on  the  left  (temporal)  side,  but 
nowhere  else  is  the  boundary  of  the  disc  recognizable.  The  large 
size  of  the  veins  is  very  conspicuous,  and  there  is  white  tissue  about 
the  vessels,  arteries  especially,  in  the  centre  of  the  disc,  very  con- 
spicuous against  the  red  surface. 

The  left  disc  presented  nearly,  but  not  quite,  the  same  appearance, 
and  after  a  few  weeks  its  congestion  lessened  much  more  than  that 
of  the  right. 

FIGS.  3  &  4. — Commencinff  optic  neuritis  ;  "congestion  with  oedema  ;  " 
probable  cerebral  syphiloma.  Left  eye. 

The  patient,  aged  twenty-five,  had  had  a  hard  chancre  at  twenty ; 
subsequently  cranial  nodes ;  an  attack  of  right  hemiplegia  at  twenty- 
three,  and  headache  and  convulsions  for  six  months.  Right  optic 
disc  full  coloured,  but  otherwise  normal.  The  appearance  of  the 
left  is  shown  in  the  figures. 

FIG.  3. — Appearance  on  an  indirect  examination.  The  edge  of  the 
disc  is  fairly  distinct,  but  its  surface  is  uniformly  red — a  deeper  and 
more  carmine  red  than  the  adjacent  choroid.  Around  it  is  a  pale 
halo,  and  this  can  be  traced  upwards  and  downwards  along  the  course 
of  the  larger  vessels,  in  the  situation  in  which  the  nerve  fibres  are 
most  numerous.  The  retinal  vessels  are  of  nearly  normal  size,  clear 
to  their  emergence  in  the  middle  of  the  disc.  (The  arteries  in  the 
figure  are  rather  too  small.) 

FIG.  4. — Appearance  of  the  same  disc  on  examination  by  the  direct 
method  (reduced).  The  edge  of  the  disc  can  nowhere  be  seen ;  the 
pale  halo  is  seen  as  a  striated,  reddish-grey,  slightly  prominent 
•opacity,  completely  veiling  all  behind  it.  The  increased  redness  in 
the  centre  is  the  only  indication  of  the  position  of  the  optic  disc. 
The  opacity  ceases  abruptly,  except  above  and  below,  where  a  fine 
striation  accompanies  the  vessels — the  pale  reflection  recognized  in 
the  inverted  image.  The  veins  are  a  little  larger  than  normal ;  they 
curve  down  the  sides  of  the  swelling,  but  the  prominence  being 
slight,  the  change  of  plane  causes  only  a  slight  diminution  of  the 
central  reflection.  The  edge  of  the  swelling  is  steepest  on  the  tem- 
poral side  (to  the  right),  and  there  a  small  vein  forms  a  conspicuous 
•curve  down  the  side. 

Vision  j|.     Field  and  colour-vision  normal. 

FIGS,  o  &  6. — Optic  neuritis.  Right  optic  disc  of  a  patient  suffering 
probably  from  a  cerebral  tumour,  causing  fits  beginning  in  the  right  side 
of  the  face.  Man  aged  thirty. 

FIG.  5  represents  the  papilla  as  seen  by  the  indirect  method.  The 
outlines  of  the  disc  cannot  be  seen ;  its  position  is  occupied  by  a 
roundish  prominent  swelling,  the  centre  of  which  is  red,  the  outer 
part  pale,  and  the  sloping  side  greyish.  The  veins  present  con- 
spicuous curves  as  they  course  down  the  sides  of  the  swelling.  They 
cannot  be  traced  to  the  middle  of  the  swelling,  their  terminations 


PLATE  IT. 


DESCRIPTION    OF    PLATES.  307 

being  concealed  in  the  red  centre.  The  arteries  cannot  be  recognized 
on  the  swelling,  being  visible  only  beyond  its  edge,  where  they  have 
a  normal  course.  (In  the  figure  they  are  rather  too  narrow.) 

FIG.  6. — The  same  disc  as  seen  by  the  direct  method  of  examination 
{reduced).  Its  prominence  is  less  conspicuous,  but  is  indicated  by 
the  curves  of  the  veins,  and  so  great  was  it  that,  although  the  fundus 
was  distinct  without  a  correcting  lens,  the  top  of  the  swelling  could 
only  be  seen  with  -J-  2  D.  The  centre  is  red,  and  presents  a  fine 
stippling;  the  outer  part  reddish-grey,  striated.  The  veins  are 
larger  than  normal,  and  being  numerous,  are  no  doubt  considerably 
enlarged.  Over  the  prominence  of  the  swelling  their  reflection  is 
bright;  but  it  is  lost,  and  the  vessels,  appear  dark,  as  they  pass  down 
the  sides  of  the  swelling.  Beyond  its  edge  several  of  them  are  par- 
tially concealed  as  they  dip  into  the  substance  of  the  retina  before 
assuming  a  normal  course  upon  the  fundus.  Towards  the  slightly- 
depressed  centre  they  are  lost  in  the  tissue,  some,  as  the  lower  veins, 
gradually,  others  suddenly  after  a  slight  curve,  in  which  their  central 
reflection  is  again  lost.  One  or  two  arteries  can  be  traced  over  the 
outer  part  of  the  swelling,  and  present  there  a  bright  reflection. 
Others  are  concealed  completely  by  the  tissue,  and  only  appear 
beyond  its  edge.  Near  the  centre  of  the  disc  is  a  small  oval  white 
spot.  On  the  right  (tenfporal  or  macular)  side  of  the  disc  the  red  of 
the  choroid  is  varied  by  a  series  of  paler  lines,  most  being  concentric 
with  and  adjacent  to  the  edge  of  the  swelling.  They  depend  on  the 
folds  into  which  the  retina  (perhaps  only  its  nuclear  layers)  is 
thrown,  in  consequence  of  its  displacement  from  the  edge  of  the 
choroid — partial  detachment.  (Compare  PL  VII.  1,  Fig.  9,  p.  58,  and 
Fig.  17,  p.  61.)  Vision  f,  but  considerable  concentric  limitation  of 
the  field.  The  condition  of  the  discs  remained  the  same  when  last 
seen,  several  months  after  the  drawings  were  made. 


PLATE  II. 

FIG.  1. — Subsiding  neuritis ;  commencing  consecutive  atrophy.  From 
<i  case  of  local  chronic  meningitis,  with  changes  (induration,  fyc.)  in  the 
subjacent  convolution,  probably  syphilitic.  Left  eye.  Woman  aged 
tiventy-five. 

After  optic  neuritis  had  lasted  about  three  months,  the  vision 
began  to  fail,  and  was  soon  reduced  to  bare  perception  of  large 
objects  in  the  lower  outer  part  of  each  field.  At  this  time  the 
swelling  of  the  discs  was  at  its  height,  but  the  injection  was  becoming 
less  marked.  A  fortnight  later,  sight  improved  considerably  in  both 
«yes,  so  that  she  could  read  large  type.  This  improvement,  however, 
was  only  temporary,  as  a  second  failure  occurred  in  the  following 
month,  leading  rapidly  to  blindness.  The  discs  had  now  become 
much  paler  and  the  veins  smaller  (the  drawing  was  made  at  this 


MEDICAL    OPHTHALMOSOOPY. 

stage),  and  the  appearances  remained  practically  unaltered  till  her 
death  a  few  weeks  later. 

The  position  of  the  disc  is  occupied  by  a  pale  swelling  with  very 
soft  edges  and  depressed  centre,  in  which  a  little  of  the  redness  still 
remains.  The  area  of  the  swelling  is  considerably  larger  than  the 
disc,  and  its  prominence  is  considerable,  as  is  shown  by  the  curves 
formed  by  the  veins  as  they  course  down  its  sides.  Several  are 
slightly  concealed  beyond  the  edge  of  the  swelling.  The  arteries 
have  an  almost  straight  course.  Both  veins  and  arteries  are  a  little 
more  concealed  at  the  centre.  The  veins,  on  the  fundus  especially, 
are  distinctly  smaller  than  they  were  in  an  early  stage.  The  small 
vessels  are  also  much  smaller,  many  having  disappeared,  and  others 
can  only  be  traced  as  fine  lines.  Vision  0. 

FIG.  2. — Neuritis  subsiding  irregularly,  clearing  from  the  upper  half 
of  the  disc  before  the  lower,  in  a  case  of  syphilitic  disease  of  the  brain. 
Left  eye. 

The  lower  half  of  the  disc  is  concealed  by  a  greyish-red,  striated 
swelling,  of  moderate  prominence.  The  veins  curve  over  it.  An 
artery  is  partially  concealed  by  it.  The  upper  portion  of  the  disc — 
rather  more  than  half — is  clear,  but  has  a  "filled-in"  look,  being 
occupied  by  new  tissue  of  a  pale  grey  tint.  A  large  vein  has  a 
peculiar  course,  curving  round  the  upper -edge  of  the  disc.  The 
arteries  are  partially  concealed  by  the  new  tissue ;  they  appear 
narrow  and  indistinct,  and  both  these  and  the  vein  are  bordered  by 
whiter  tissue.  Similar  white  tissue  marks  the  position  of  several 
small  vessels,  which  can  scarcely  be  distinguished. 

FIG.  3. — Grey  atrophy  of  optic  nerve,  probably  from  post-orbital 
pressure  on  the  nerve  trunk.  Left  eye.  Woman  aged  fifty-nine. 

The  disc  presents  an  iron-grey  tint,  greenish  in  daylight,  uniform 
in  the  outer  part,  but  mottled  at  the  bottom  of  the  central  cup,  grey 
flake-like  spots  being  separated  by  the  white  trabeculae  of  the  lamina 
cribrosa.  The  central  cup  is  deep  and  wide.  The  sclerotic  ring  is 
visible  in  almost  the  whole  circumference  of  the  disc.  The  vessels 
present  no  reduction  in  size.  They  are  distinct  to  their  emergence. 
The  veins  join  to  form  a  trunk,  which  can  be  seen  dimly  as  it 
passes  down  into  the  substance  of  the  nerve  in  the  central  cup. 
Along  one  artery,  which  passes  downwards  and  crosses  two  veins, 
white  lines,  indicating  the  position  of  the  wall  of  the  vessel,  are 
distinct  against  the  darker  veins.  Vision  0. 

This  patient  was  distinctly  rheumatic,  and  had  an  attack  of  facial 
palsy  apparently  of  this  nature.  Eighteen  months  later,  after 
exposure  to  cold,  she  had  complete  paralysis  of  all  the  motor  nerves 
of  one  orbit,  and  blindness  of  the  corresponding  eye.  The  motor 
nerves  recovered  under  treatment,  while  the  eye  remained  quite 
blind.  There  was  never  any  papillitis,  but  the  disc  slowly 
atrophied. 

FIG.  4. — Atrophy  of  optic  disc,  of  *i.r  years'  duration,  secondary  to 


DESCRIPTION    OF    PLATES.  309 

pressure  on  optic  commissure  after  previous  slight  damage  by  neuritis. 
Right  eye.  Man  aged  thirty-four. 

To  indirect  examination  the  disc  appeared  white,  but  on  direct 
examination  it  is  everywhere  of  a  faint  greenish-grey  tint,  strongly 
marked  at  the  bottom  of  the  central  depression.  The  veins  and 
arteries  are  of  nearly  normal  size.  The  edge  of  the  disc  is  a  little 
irregular  in  shape,  and  the  appearance  of  irregularity  is  increased 
by  a  narrow  zone  of  atrophy  of  the  choroid  on  the  temporal  (left) 
side,  within  which  pigment  is  accumulated  in  a  narrow  line  at  the 
edge  of  the  disc.  This  is  probably  a  relic  of  the  attack  of  neuritis, 
and  so  also  is  the  appearance  of  white  lines  along  the  lower  vein  ; 
the  latter  was  much  more  conspicuous  soon  after  the  neuritis  sub- 
sided. The  disc  has  a  "  fllled-in  "  look,  the  excavation  being  slighter 
than  in  the  case  of  simple  atrophy  shown  in  Figs.  3  and  6,  and  the 
lamina  cribrosa  being  invisible.  Vision  0. 

During  the  optic  neuritis  his  vision  was  at  one  time  reduced  to 
barely  counting  fingers,  but  it  afterwards  improved  to  nearly  normal 
during  the  stage  of  subsidence.  After  this  his  sight  failed  tem- 
porarily and  improved  again  on  several  occasions,  without  there 
being  any  ophthalmoscopic  change.  Finally,  nearly  two  years  after 
the  papillitis,  there  was  rapid  failure  of  sight,  which  soon  culminated 
in  almost  complete  blindness.  (See  p.  167.) 

FIG.  o. — Atrophy  of  the  left  optic  nerve  in  a  case  of  cerebral  disease, 
causing  left  hemiplegia,  amaurosis  of  left  eye,  and  loss  of  the  left  half 
of  the  field  of  vision  in  the  right  eye. 

The  disc  appeared  white  and  sharp-edged  to  the  indirect  method, 
but  by  the  direct  method  is  pale  grey.  The  tint  is  pale  and  uniform 
in  the  outer  part,  and  in  the  centre  there  is  a  deeper  grey  mottling 
within  the  lamina  cribrosa.  The  edge  is  clear  and  shai'p  all  round. 
On  the  temporal  side  (to  the  right)  is  a  little  accumulation  of 
pigment.  The  veins  and  arteries  are  of  normal  size,  and  can  be 
traced  to  the  bottom  of  the  large  central  cup.  A  small  vessel  passes 
on  to  the  disc  from  the  choroid,  and  thence  on  to  the  retina. 
Vision  0.  Boy  aged  fourteen.  The  paralysis  and  blindness  came 
on  suddenly  during  a  fit  one  year  after  fracture  of  skull.  The  nature 
of  the  cerebral  lesion  remained  hypothetical.  (See  charts  of  visual 
fields,  Figs.  42,  43,  p.  73.) 

FIG.  6. — Atrophy  of  the  optic  nerves  of  three  years'  duration  in  a 
patient  presenting  slight  spinal  symptoms  (rheumatic  pains  in  legs, 
darting  pains  in  back,  satyriasis,  and  excessive  knee-jerk}.  Right 
eye. 

The  optic  disc  is  sharp-edged,  the  sclerotic  ring  conspicuous  on  the 
temporal  side,  and  beyond  it  a  little  pigment-accumulation.  The 
nasal  half  of  the  disc  (to  the  right)  is  a  soft  uniform  grey ;  the 
temporal  half  to  the  left  is  darker  grey,  mottled.  The  excavation 
is  large,  and  at  the  bottom  the  lamina  cribrosa  is  visible.  Vision  : 
quantitative  perception  of  light  only.  Both  discs  similar. 


310  MEDICAL    OPHTHALMOSCOPY. 


PLATE  III. 

FIGS.  1  &  2. — Right  and  left  optic  discs  ;  caries  of  sphenoid  bone,  with 
secondary  meningitis.  (See  p.  179.) 

FIG.  1. — Right  optic  disc.  Characters  normal.  Outline  clear ;  central 
cup  deep ;  vessels  lost  to  view  as  they  pass  down  its  sides.  The 
termination  of  the  vein  can  be  dimly  seen  in  the  middle,  beneath  the 
nasal  edge  of  the  hollow.  (Vision  normal.) 

FIG.  2. — Left  optic  disc.  Well-marked  neuritis.  Edge  of  disc  in- 
visible ;  concealed  by  a  reddish-grey  swelling,  which  extends  beyond 
the  normal  limits  of  the  disc.  The  central  cup  is  encroached  upon 
but  not  quite  obliterated,  a  small  area  of  white  reflection  from  it 
being  still  visible.  Vessels  of  normal  size.  The  veins  emerge  from 
the  central  depression ;  one,  which  passes  directly  upwards,  being 
partly  concealed  at  its  emergence ;  they  present  conspicuous  curves 
and  lose  their  central  reflection  as  they  course  down  the  sides  of  the 
swelling.  The  arteries  present  a  straighter  course,  but  cannot  be 
easily  distinguished  upon  the  papilla.  The  degree  of  swelling  is 
moderate ;  it  presents  fine  striation,  partly  due  to  minute  radiating 
vessels  and  partly  to  the  nerve  fibres.  (Vision  quantitative  only.) 

FIG.  3. — Descending  neuritis  in  cerebral  tumour.  Man  aged  ticenty- 
four.  (See  p.  159.) 

Right  optic  disc.  Outline  recognizable  on  the  temporal  side, 
although  not  sharp ;  concealed  on  the  nasal  side.  Tint,  greyish-red, 
finely  striated.  Swelling  distinct  but  slight.  Veins,  of  normal  size, 
lose  their  bright  reflection  on  the  sides  of  the  swelling  and  are  con- 
cealed just  beyond  its  edge;  one,  which  passes  downwards  and  to  the 
right,  is  concealed  near  the  middle  of  the  papilla  by  a  white  opaque 
spot.  The  arteries  are  narrow,  and  near  the  middle  of  the  papilla 
are  bordered  by  white  lines.  (Vision  could  not  be  ascertained.) 
For  the  microscopical  appearances  at  a  later  stage,  when  the  inflam- 
mation was  greater,  see  Figs.  9,  12,  16,  17,  29,  30,  31,  and  XIV.  1. 

FIG.  4. — Optic  neuritis  in  cerebral  tumour  ;  tubercular  masses  in  cere- 
bral hemis2)heres,  cerebellum,  and  the  other  eye.  Boy  ayed  eight. 

Left  optic  papilla.  Disc  concealed  by  very  prominent  swelling 
with  a  marked  central  depression.  Veins  large,  and  form  conspicu- 
ous curves  as  they  course  down  the  steep  sides  of  the  swelling,  some 
being  even  lost  to  view  in  their  course  on  account  of  the  steepness. 
Beyond  the  edge  they  are  obscured  for  a  short  distance.  Arteries 
partly  concealed.  Minute  red  stippling  of  swelling,  but  no  haemor- 
rhages. Much  white  tissue  about  the  vessels  in  the  central  depres- 
sion. Vision :  slight  failure  only. 

FIGS.  5  &  6. — Optic  neuritis  in  traumatic  meningitis  and  after  re- 
covery. Right  eye.  (Case  mentioned  on  p.  186.) 

FIG.  5. — Appearance  ten  days  after  the  injury.  A  pale  red,  striated 
opacity  conceals  the  whole  disc,  the  edge  being  nowhere  visible ; 
prominence  slight  but  distinct.  The  central  cup  is  not  quite  oblite- 


PLATE   III. 


PLATE    IV 


DESCRIPTION    OF    PLATES.  311 

rated ;  its  white  reflection  is  visible  at  the  bottom  oi'  the  central 
depression.  Veins  of  normal  size ;  the  upper  branches,  where  the 
swelling  is  greatest,  lose  their  reflection  at  the  edge.  Arteries  of 
normal  course.  Vision :  no  evidence  of  impairment. 

FIG.  6. —  The  same  disc  a  month  later,  presenting  normal  characters. 
Edge  clear  and  fairly  sharp ;  sclerotic  ring  visible  on  nasal  side  (to 
the  right).  Central  pit  clear  and  apparently  normal ;  steep  on  the 
temporal  (left),  sloping  on  the  nasal  side.  The  edge  of  the  disc 
is  seen  by  its  relation  to  the  vessels  to  be  considerably  within  the 
limits  of  the  swelling  shown  in  the  preceding  figure.  The  vessels  have 
a  normal  course.  Vision  normal. 


PLATE  IV. 

FIGS.  1  &  2. —  Optic  neuritis  in  a  case  of  probable  syphiloma  of  brain, 
and  disc  after  recovery.  Right  eye.  Man  aged  thirty-three. 

FIG.  1. — Inflamed  papilla.  Disc  concealed  by  a  prominent,  red, 
striated  swelling  about  twice  the  normal  diameter  of  the  disc.  A 
slight  central  depression  can  be  seen.  The  veins,  not  larger  than 
normal,  appear  dark  as  they  pass  down  the  sides  of  the  swelling.  A 
white  patch  lies  across  and  conceals  one  which  passes  downwards. 
On  the  lower  pai't  of  the  swelling  is  a  small  haemorrhage.  Vision  : 
No.  1  Jager  at  six  inches  with  a  little  difficulty. 

FIG.  2. —  The  same  disc  three  months  later,  presenting  very  little  trace 
of  the  preceding  inflammation.  Outline  quite  clear  and  skarp ; 
sclerotic  ring  distinct ;  no  disturbance  of  adjacent  choroid.  Central 
cup  small  but  not  apparently  "  filled-in/'  as  the  veins  can  be  traced 
down  its  sides  to  their  junction  at  the  bottom.  Some  of  the  arteries 
on  the  disc  are  accompanied  by  white  lines,  especially  one  which 
curves  downwards.  A  comparison  of  the  vessels  with  those  in  the 
last  figure  will  show  how  much  they  were  altered  in  their  course  by 
the  swelling.  [A  vein  which  passes  upwards  and  to  the  left  has  by  an 
error  been  drawn  as  an  artery.]  Vision  normal. 

FIGS.  3  &  4. — Optic  neuritis  from  cerebral  syphiloma,  and  same  disc 
after  the  subsidence  of  the  neuritis.  Woman  aged  thirty-seven. 

FIG.  3.— Inflamed  papilla.  Disc  concealed  under  a  swelling  of 
moderate  prominence,  and  about  twice  the  diameter  of  the  normal 
disc,  concealing  the  veins  and  arteries.  Colour  red,  and  finely  punc- 
tate in  the  centre ;  greyish-red  and  striated  on  the  peripheral  por- 
tions of  the  swelling.  The  central  reflection  of  the  veins  is  lost  as 
they  slope  down  the  sides  of  the  swelling.  Veins  a  little  larger  than 
normal ;  arteries  nearly  of  normal  size.  One  vein,  which  courses 
from  below,  passes  over  the  disc  more  superficially  than  the  others 
and  presents  a  double  curve.  There  is  a  small  hemorrhage  in  the 
centre  of  the  disc,  and  a  faint  white  spot  to  the  right  of  the 
centre. 


312  MEDICAL   OPHTHALMOSCOPY. 

Vision  =  YJ  andy8^.  Field  normal.  Blind  spot  double  normal  size. 
(Fig.  38,  p.  70.) 

FIG.  4. — The  same  disc  two  months  later.  Neuritis  gone ;  outline  of 
disc  clear  in  whole  circumference.  There  is  a  fringe  of  pallor 
beyond  the  nasal  edge,  to  the  left  (atrophy  of  choroidal  pigment). 
Tint  of  disc  normal,  but  too  uniform,  and  the  disc  has  a  "  filled-in  " 
aspect,  the  two  lower  veins  being  narrowed  and  partly  concealed  by 
new  tissue  at  the  centre  left  by  the  inflammation.  The  normal 
central  "cup"  is  being  re-established,  as  shown  by  the  curve  at  the 
central  end  of  the  lower  vein ;  the  bright  reflection  is  lost  as  the 
vein  curves  down  the  edge  of  the  cup ;  at  the  centre  it  is  still  almost 
concealed.  Arteries  normal. 

Vision  the  same. 

FIGS.  5  &  6. — Subsiding  neuritis  and  subsequent  atrophy  (cerebral 
syphiloma) ;  process  of  obliteration  of  vessels.  Left  eye.  Man  aycd  thirty- 
four. 

FIG.  5. — Neuritis  subsiding.  A  month  previously  intense  inflam- 
mation with  hsemorrhages.  Now  a  pale  reddish-white  prominence 
remains,  with  soft  edges,  paler  in  the  centre  than  at  the  margin. 
The  veins,  large  and  dark,  curve  over  the  side  of  the  swelling,  and 
are  obscured  just  beyond  the  edge.  The  arteries  are  small  and 
partially  concealed  by  the  new  tissue.  On  the  surface  several  vessels 
are  seen  in  process  of  obliteration.  One,  apparently  an  artery,  ends 
suddenly  at  a  small  extravasation,  and  the  terminal  portion  of  the 
vessel  is  very  dark,  as  if  plugged.  From  the  central  portion  of  the 
vessel  two  small  branches  proceed. 

Vision  0.    Galvanic  stimulation,  no  effect. 

FIG.  6. —  The  same  disc  six  weeks  later.  The  swelling  has  subsided 
almost  to  the  level  of  the  retina ;  the  surface  of  the  disc  is  white,  the 
centre  (in  the  position  of  the  physiological  cup)  being  a  little  whiter 
than  the  rest.  Veins  and  arteries  are  somewhat  smaller  than 
normal,  the  latter  especially.  The  veins  have  now  a  straight  course, 
and  the  arteries  can  be  traced,  although  narrowed  and  obscured,  to 
their  emergence  near  the  centre  of  the  disc.  The  small  vein  in  the 
other  figure  which  had  a  peculiar  serpentine  course  has  disappeared. 
The  artery,  which  appeared  to  be  in  part  plugged,  presents  a 
very  different  appearance.  The  distal  part  has  disappeared,  and  the 
proximal  portion  has  dwindled  in  size  to  that  of  the  branch,  which 
appears  to  be  carrying  on  the  blood  from  it.  Its  origin  from  a  larger 
trunk  is  now  clear. 

Vision :  very  slight  perception  of  light ;  retina  again  sensitive  to 
electrical  stimulation. 


PLATE    V 


DESCRIPTION   OF   PLATES.  313 


PLATE  V. 

FIGS.  1  &  2. — Optic  neuritis  (right  and  left  eyes)  in  cerebral  tumour. 

The  patient  (in  the  National  Hospital  for  the  Paralysed  and 
Epileptic  under  the  care  of  Dr.  Hughlings- Jackson)  was  a  man 
aged  thirty-five,  suffering  from  left-sided  convulsions,  beginning 
with  a  visual  and  auditory  aura  (referred  to  the  left  ear),  and  from 
left  hemiopia  of  both  eyes.  Subsequently  coarse  tremor  came  on 
in  the  left  arm,  with  weakness,  which  gradually  increased  to 
complete  left  hemiplegia.  The  symptoms  were  found  to  be  due 
to  a  tumour  of  the  right  hemisphere,  in  the  parietal  and  temporo- 
sphenoidal  lobes,  extending  inwards. 

FIG.  1. — Left  disc.  Inner  half  veiled  beneath  a  reddish  striated 
swelling  of  slight  prominence,  sufficient  to  alter  a  little  the  course 
of  the  veins  and  partially  conceal  the  arteries.  The  outer  half  is 
much  less  red,  and  its  outline  can  be  seen,  but  is  soft.  A  flame- 
shaped  haemorrhage  lies  across  the  edge,  having  one  extremity 
adjacent  to  a  small  vein.  There  is  another  small  extravasation 
near  an  artery  on  the  lower  margin.  Vision  normal,  except  for  the 
hemiopia. 

FIG.  2. — Right  disc  presenting  a  similar  appearance ;  the  inner  half 
concealed,  the  outer  visible,  but  not  clear.  No  extravasation. 

During  about  six  months  that  the  patient  remained  under  observa- 
tion not  the  slightest  change  could  be  seen  in  the  discs  except  the 
disappearance  of  the  haemorrhages.  A  year  and  a  half  later  (two 
years  after  the  drawings  were  made)  vision  had  entirely  failed.  The 
inner  halves  of  the  discs  were  still  concealed  under  a  reddish  striation, 
but  the  outer  halves  had  become  grey,  without  any  redness. 

FIG.  3. — Optic  neuritis  in  a  case  of  cerebral  syphilitic  disease,  causing 
left-sided  weakness  and  convulsions  beginning  in  the  hand.  Left  eye. 

Disc  completely  concealed  on  nasal  side  (to  the  left),  while  on 
temporal  side  (to  the  right)  the  position  of  the  edge  can  just  be 
detected.  Swelling  moderate,  altering  the  course  of  the  veins,  which 
can,  however,  be  traced  up  to  their  emergence  in  the  centre.  The 
curve  they  present  at  the  edge  of  the  swelling  is  gentle,  but  their 
central  reflection  is  lost  there.  The  more  abrupt  backward  curve 
presented,  just  beyond  the  edge  of  the  disc,  by  a  vein  which  passes 
directly  downwards,  is  apparently  determined  by  the  position  of  an 
artery  which  crosses  it,  and  which  a  little  above  this  point,  in 
crossing  it  again,  has  again  depressed  it.  A  small  vein  which  passes 
upwards  and  to  the  left  (in  the  figure)  is  concealed  for  some  distance 
by  the  striated  opacity.  On  the  upper  edge  of  the  swelling  is  a  small 
haemorrhage.  Neuritis  bilateral.  Vision  i.  Colour-vision  normal. 

FIG.  4. — Optic  neuritis  in  cerebral  tumour, probably  tubercular,  causing 
left  hemiplegia  and  hemiopia.  Left  eye.  Girl  aged  fifteen. 

The  temporal  part  of  the  disc  (to  the  right  in  the  figure)  is  clear, 


814  MEDICAL    OPHTHALMOSCOPY. 

its  outline  being  quite  distinct.  Elsewhere  the  margin  of  the  disc 
is  concealed  by  a  (reddish)  striated  opacity,  of  slight  prominence. 
The  veins  are  large,  and  those  which  pass  downwards  curve  a  little 
over  the  edge  of  the  swelling,  while  one,  which  passes  upwards  and 
does  not  curve,  is  concealed  at  the  edge.  A  small  striated  haemor- 
rhage lies  over  an  artery  above,  the  striation  being  in  the  direction 
of  the  nerve  fibres.  The  course  of  the  artery  is  not  changed.  Below 
is  a  still  smaller  extravasation  upon  a  minute  branch  of  a  vein. 
Vision :  No.  10  Jager  at  one  foot ;  hemiopia ;  all  colour-vision  lost. 
Both  eyes  similar.  The  patient  improved  under  treatment,  the 
disappearance  of  the  neuritis  being  the  first  sign  of  the  improvement. 
In  a  few  weeks  the  aspect  of  the  discs  became  perfectly  normal,  and 
has  continued  so  now  for  five  years. 

FIG.  5. — Optic  neuritis  in  cerebral  tumour.  Glio-sarcoma,  springing 
from  the  membranes,  and  compressing,  without  invading,  the  right 
side  of  the  pons  and  1'ight  hemisphere  of  the  cerebellum,  causing 
right-sided  convulsions  beginning  in  the  hand,  and  afterwards  left- 
sided  attacks  beginning  in  the  face ;  weakness  and  coarse  tremor  in 
the  right  limbs,  deafness  in  the  right  ear,  and  trophic  changes  in  the 
right  eye. 

The  drawing  was  made  as  the  neuritis  was  beginning  to  subside. 
Disc  concealed  beneath  a  considerable  swelling,  red  and  striated. 
Veins  large  (beginning  to  lessen  in  size),  curve  over  the  edge  of  the 
swelling.  One  which  passes  down  cannot  be  traced  beyond  the  edge, 
where  it  apparently  disappears.  (Even  when  the  neuritis  had  sub- 
sided still  more,  its  further  course  could  not  be  detected.)  Arteries 
small,  not  more  than  one-half  the  size  of  the  veins.  Vision  0. 

FIG.  6. — Optic  neuritis  in  cerebral  tumour.  Right  eye.  Woman  ayed 
thirty-three. 

The  neuritis  was  in  course  of  subsidence.  Swelling  considerable, 
completely  concealing  the  disc,  pale,  but  still  reddish,  darker  around 
the  margin.  The  veins  form  conspicuous  curves  at  the  edge  of  the 
swelling,  one  above  forming  a  double  curve  in  consequence  of  passing 
beneath  an  artery  just  within  the  edge  of  the  swelling.  All  the 
veins  are  concealed  for  a  short  distance  beyond  the  edge,  and  then 
resume  a  normal  course  upon  the  retina.  Vision:  reads  No.  12 
Jager  at  a  foot.  The  neuritis  subsided  into  consecutive  atrophy, 
sight  gradually  failing  until  vision  was  completely  and  permanently 
lost. 

The  exact  nature  of  the  intracranial  condition  remained  obscure  ; 
there  was  a  family  history  both  of  tubercle  and  cancer.  Mental 
power  soon  failed  greatly.  The  condition  was  similar  in  the  two 
optic  nerves. 


PLATE    VI. 


DESCRIPTION   OF    PLA'I  F>.  315 


PLATE   VI. 

FIG.  1. — Intense  optic  neuritis,  with  retinal  haemorrhages,  in  a  case  of 
cerebral  tumour.  Right  eye.  Man  aged  thirty-six. 

The  region  of  the  optic  disc  is  occupied  by  a  large  swelling,  in  width 
about  four  times  the  diameter  of  the  disc.  It  is  irregular  in  outline, 
with  very  steep  sides,  and  is  bounded  in  every  direction  by  extravasa- 
tions. Some  of  these  are  more  or  less  striated,  others  have  a  sharp 
convex  edge,  due  to  their  position  in  the  overhanging  edge  of  the 
swelling.  The  surface  of  the  prominence  is  of  about  the  same  tint  as 
the  fundus.  The  vessels  are  concealed  in  the  substance  of  the  swell- 
ing, except  one  or  two,  the  position  of  which  is  dimly  seen.  Most  of 
them  appear  first  beyond  its  edge,  and  are  then  of  about  normal  size, 
but  at  first  they  form  conspicuous  curves,  the  deeper  portions  of 
which  are  concealed.  They  then  assume  a  nearly  normal  course. 
The  arteries  are  narrow,  some  being  scarcely  visible.  Numerous 
haemorrhages,  small  and  striated,  are  scattered  over  the  retina  in  the 
posterior  half  of  the  eyeball,  except  on  the  temporal  side  (to  the 
left).  In  this  direction  the  swelling  reaches  almost  to  the  position  of 
the  macula  lutea,  in  the  neighbourhood  of  which  are  many  minute 
white  dots  adjacent  to  the  edge  of  the  swelling.  Vision  0. 

The  patient  died,  but  no  post-mortem  examination  was  permitted. 

FIG.  2.—  Optic  neuritis  in  a  case  of  old  fractures  of  the  skull;  inflam- 
matory growths  beneath  them  ;  at  the  base  the  results  of  previous  menin- 
gitis. Man  aged  forty-nine. 

The  position  of  the  disc  could  be  recognized  by  the  indirect  method 
of  examination,  but  the  edge  was  softened.  The  area  of  the  disc  was 
bright  red,  and  beyond  the  edge  was  a  pale  halo.  In  the  upright 
image  the  edge  is  completely  concealed  under  a  greyish -red  swelling, 
of  nearly  three  times  the  diameter  of  the  disc,  striated.  Upon  it  are 
many  white  spots  and  lines  (due  to  granule  corpuscles,  &c.),  some  of 
which  correspond  to  the  course  of  the  arteries.  One,  above,  is  sur- 
rounded by  a  narrow  zone  of  haemorrhage.  The  vessels  are  concealed 
in  the  middle  of  the  swelling ;  the  veins  more  completely  than  some 
of  the  arteries.  The  course  of  the  veins  is  very  tortuous.  Vision  TL. 
(The  microscopical  appearances  are  shown  in  Figs.  13,  23,  24,  33.) 

FIG.  3. — Neuritis  subsiding  into  atrophy;  slight  retinal  changes; 
tubercle  of  cerebellum.  J^eft  eye.  Soy  aged  eleven. 

The  disc  is  invisible  beneath  a  pale,  almost  white  swelling, 
depressed  in  the  centre.  Over  this  the  veins  curve.  After  sloping 
down  its  sides,  they  are  concealed  by  the  adjacent  opacity  of  the 
retina  for  a  short  distance.  One  artery,  which  passes  downwards,  is 
visible  on  the  surface  of  the  swelling,  but  is  also  concealed  beyond  its 
edge.  The  other  arteries  appear  only  some  distance  from  the  edge. 
Midway  between  the  retina  and  the  macula  lutea  is  a  group  of  small 
white  granular-looking  spots,  apparently  just  behind  the  level  of  a 


316  MEDICAL   OPHTHALMOSCOPY. 

retinal  vessel  which  passes  among  them.  (They  slowly  lessened 
under  observation.  The  swelling  gradually  subsided,  the  edges  of 
the  disc  reappearing  and  its  aspect  becoming  that  of  "  consecutive 
atrophy."  Its  appearance  is  shown  in  section  in  Figs.  49,  50.) 
Vision  0. 

He  died  from  meningitis,  probably  tubercular.  At  the  necropsy 
tubercles  were  found  in  the  cerebellum  and  medulla  oblongata. 

FIGS.  4  &  5. — Subsiding  neuritis,  recent  haemorrhages,  and  same  disc 
after  recovery. 

The  patient  had  been  in  the  London  Hospital,  under  the  care  of  Dr. 
Hughlings-Jackson,  suffering  from  the  symptoms  of  cerebral  tumour, 
and  presenting  intense  optic  neuritis.  Under  treatment  the  symp- 
toms subsided  and  the  neuritis  gradually  lessened,  but  during  sub- 
sidence several  fresh  haemorrhages  appeared.  He  died  some  years 
later,  and  the  brain  presented  softening  of  one  anterior  lobe,  with  the 
remains  of  an  absorbed  syphilitic  gumma.  Cicatrices  were  also 
found  in  the  liver. 

FIG.  4. — Subsiding  neuritis.  The  outline  of  the  disc  can  be  seen,  but 
is  not  clear ;  its  surface  is  reddish  in  tint,  and  the  swelling  of  the 
papilla  is  still  considerable,  as  evidenced  by  the  curves  formed  by  the 
veins  in  passing  over  its  edge.  Several  large  extravasations  are  seen. 
One  of  these,  below,  follows  the  course  of  an  artery.  Another  above 
and  to  the  left  is  round,  not  striated,  and  therefore  probably  situated 
in  the  deeper  layers  and  not  in  the  nerve-fibre  layer.  Vision  f ;  fields 
normal. 

FIG.  5. —  The  same,  tico  months  later.  The  haemorrhages  have  entirely 
disappeared.  The  disc  is  clear,  and  its  swelling  has  almost  subsided. 
But  the  tortuosity  of  the  vessels  has  increased,  probably  on  account 
of  their  permanent  extension  by  the  long-continued  swelling. 


PLATE  VII. 

FIGS.  1  &  2. —  Unilateral  optic  neuritis;  probably  cerebral  x 
Man  aged  forty-four. 

FIG.  1. — Left  optic  disc  concealed  by  a  swelling — reddish,  striated, 
depressed  in  the  centre.  The  veins,  a  little  larger  than  normal, 
curve  over  it,  and  some  are  concealed  beyond  the  edge.  In  the 
central  depression  the  veins  pass  behind  the  arteries  and  are  unduly 
concealed  by  the  swollen  tissue.  The  artery  which  passes  upwards 
is  visible  throughout ;  those  which  pass  downwards  are  distinct  at 
their  emergence  in  the  depressed  centre,  but  are  concealed  by  the 
swelling,  to  reappear  at  its  edge.  No  haemorrhages.  Just  beyond  the 
edge  of  the  papilla  is  a  series  of  pale  concentric  lines  parallel  to  the 
edge,  due  to  the  folds  in  the  displaced  retina ;  they  are  limited  above 
and  below  by  a  small  vein.  Vision  :  counts  fingers  only. 


PLATE    VII. 


DESCRIPTION   OF    PLATES.  317 

FIG.  -2. — Right  optic  disc  presenting  normal  characters.  A  small 
deposit  of  pigment  lies  across  a  vein. 

The  right  disc  never  became  inflamed,  but  both  discs  eventually 
became  atrophied,  doubtless  from  an  intracranial  cause.  It  is 
possible  that  both  nerves  were  damaged  in  front  of  the  commissure, 
and  that  in  one  only  did  the  inflammation  descend  to  the  eye. 

FIGS.  3  &  4.—  Very  chronic  optic  neuritis,  in  a  case  of  epileptoid  con- 
vulsions. Girl  aged  fifteen. 

FIG.  S.—Left  disc.  Outline  obscured  by  neuritic  swelling  of  slight 
prominence :  the  centre  stippled  red,  the  periphery  only  slightly 
lighter  in  tint  than  the  fundus.  Veins,  of  nearly  normal  size, 
concealed  in  centre  by  whitish  tissue,  which  accompanies  the  larger 
trunks  of  both  arteries  and  veins  for  a  short  distance.  The  double 
contour  of  the  veins  is  lost  on  the  sides  of  the  swelling.  Vision  : 
No.  2  Jager,  spells  No.  1.  Appearances  unchanged  during  four 
months'  observation. 

FIG.  4. — -The  same  disc  two  years  later.  All  swelling  is  now  gone. 
The  outline  is  clear  on  the  outer  (temporal),  indistinct  on  the  inner 
(nasal)  side.  Veins  large  ;  at  their  junction  in  the  disc  they  are  even 
more  concealed  than  before,  and  the  white  tissue  about  them  is  still 
very  conspicuous.  Vision,  same. 

FIG.  5.— Optic  neuritis  in  anaemia.     Girl  aged  seventeen. 

The  outline  of  the  disc  is  lost  under  a  pale,  reddish-grey  swelling, 
of  slight  prominence,  a  little  larger  than  the  disc.  The  veins,  of 
normal  size,  lose  their  reflection  as  they  curve  down  the  sides  of  the 
swelling,  and  some  are  obscured  beyond  its  edge  as  they  dip  into  the 
substance  of  the  retina.  Some  of  the  arteries-are  concealed  ;  others 
distinguishable  with  difficulty.  There  is  a  small  white  spot  near  the 
centre  of  the  swelling.  Vision  (uncorrected)  £. 

Eyes  hypermetropic.  Both  discs  cleared  and  vision  became 
normal.  A  few  months  later  there  was  a  temporary  return  of  the 
anaemia  and  of  the  papillitis,  but  vision  remained  normal.  (See 
p.  243.) 

FIG.  6. — Optic  neuritis  in  a  case  of  lead  poisoning,  with  cerebral 
symptoms.  Man  aged  forty-five. 

The  disc  is  concealed  by  a  swelling  of  moderate  prominence, 
bordered  by  a  fringe  of  striated  haemorrhage,  and  of  a  colour  nearly 
that  of  the  fundus.  Veins  a  little  larger  than  normal.  Arteries 
concealed  by  the  swelling,  and  most  of  them  very  narrow  on  the 
retina. 

His  vision  was  considerably  impaired,  but  could  not  be  accurately 
tested,  owing  to  his  mental  state.  (Sec  p.  272.) 


318  MEDICAL    OPHTHALMOSCOPY. 


PLATE    VIII. 

FIGS  1  &  '2. — Intense  ncuro-retinitis,  probably  idiopathic,  in  a 
chlorotic  girl,  leaving  changes  simulating  albuminuric  retinitis. 

FIG.  1. — Right  fundus  oculi  during  the  heiffkt  of  the  neuritis.  The 
papilla  presents  a  very  large  pale  red  swelling,  five  times  the 
transverse  and  six  times  the  vertical  diameter  of  the  disc.  The 
peripheral  portions  are  paler  than  the  central.  Its  sides  are  steep, 
and  marked  by  scattered  striated  haemorrhages.  Even  the  tortuous 
veins  are  almost  completely  concealed  by  the  swelling,  the  highest 
parts  of  their  curves  alone  being  seen.  At  the  edge  all  reappear,  are 
greatly  distended,  and  form  conspicuous  curves,  most  of  them  being 
again  lost  for  a  short  space  in  the  retina.  The  arteries  are  all 
concealed.  Many  extravasations  fringe  the  swelling.  The  largest 
lies  over  a  vein  which  passes  downwards :  it  is  striated,  and  has  a 
paler  centre.  The  pale  edge  of  the  swelling  is  irregular,  presenting 
several  projections,  and  beyond  it  are  many  pale  spots  in  the  retina. 
The  swelling  on  the  temporal  (left)  side  reaches  as  far  as  the  macula, 
and  just  beyond  it  is  a  group  of  white,  rod-shaped  spots,  arranged  in 
a  fan-like  manner,  and  evidently  situated  on  the  temporal  side  of  the 
macula.  There  are  a  few  small  haemorrhages  here  and  there  in  the 
fundus  beyond  the  limits  of  the  swelling.  Vision:  No.  19  Jager ; 
considerable  limitation  of  field,  especially  upwards  and  inwards. 
Loss  of  colour-vision  except  for  red. 

FIG.  2. — The  same  fundus  three  months  afterwards.  All  the  swelling 
has  disappeared.  The  disc  is  clear,  but  has  a  "  filled-in "  look,  the 
vessels  being  partly  concealed  at  their  emergence.  Both  arteries 
and  veins  are  very  narrow.  The  extravasations  have  disappeared ; 
the  white  spots  in  the  retina  persist,  but  have  a  more  granular 
aspect.  Some  extend  along  the  vessels,  and  one  or  two  have  an 
irregular  linear  course  as  if  corresponding  to  the  position  of 
ehoroidal  vessels.  Many  white  areas  lie  in  the  part  of  the  retina 
around  the  disc  which  was  formerly  occupied  by  the  swelling.  The 
fan-like  group  of  spots,  adjacent  to  the  macula,  has  become  still 
more  conspicuous,  and  others  appear  adjacent  to  them,  and  of 
similar  arrangement;  so  that  the  aspect  of  albuminuric  change  is 
very  closely  simulated.  Vision :  quantitative  perception  of  light 
only.  (See  p.  244.) 


PLATE   Vlli 


PLATE     IX 


DESCRIPTION    OF    PLATES.  '319 

PLATE    IX. 

FIG.  1 . — Haemorrhage  on  optic  disc  in  a  case  of  renal  disease,  arterial 
disease,  and  acute  cerebral  lesion.  Right  eye. 

The  optic  disc  is  otherwise  normal ;  the  central  cup  distinct,  narrow 
but  deep ;  the  arteries  and  veins  of  normal  size.  On  the  temporal 
side  of  the  disc  is  a  small  extravasation,  striated,  extending  on  the 
retina  about  a  disc's  breadth.  It  has  apparently  arisen  from  the 
rupture  of  a  small  vessel,  which  can  be  traced  to,  but  not  beyond, 
the  haemorrhage.  It  had  given  rise  to  no  symptoms. 

FIG.  2. — Neuritis  albuminurica.  Right  optic  disc  of  a  man  suffering 
from  chronic  renal  disease,  convulsions,  and  mental  derangement. 

The  disc  presents  the  signs  of  slight  but  distinct  neuritis.  Its 
outline  can  be  nowhere  seen;  there  is  slight  swelling;  the  tint  of 
the  papilla  is  red,  and  the  redness  is  striated.  Many  small  vessels 
radiate  from  it  on  to  the  retina — more  than  is  common  in  neuritis. 
The  veins  are  rather  large.  The  arteries  are  very  narrow — not  more 
than  one-half  the  diameter  of  the  veins.  One  small  haemorrhage 
exists  on  the  temporal  (left)  edge  of  the  disc.  On  the  surface  of  the 
papilla  are  several  white  spots,  irregular  in  shape.  One  is  situated 
over  an  artery,  another  near  the  middle  of  the  disc,  and  one  near  the 
lower  edge.  One  small  soft  whitish  spot  can  be  seen  on  the  retina  near 
a  vessel  above  the  disc,  but  this  is  the  only  trace  of  retinal  affection. 
(There  were  no  spots  near  the  macula  lutea.)  Vision :  No.  12  Jager. 

FIG.  3. — Albuminuric  neuritis  in  a  man  suffering  from  chronic  renal 
disease  (granular  kidney),  intense  headache,  and  who  died  shortly  after- 
wards of  uraemia.  Right  eye. 

The  disc  is  concealed  by  a  considerable  greyish-red  swelling, 
stippled  and  striated.  The  veins  are  concealed  at  their  point  of 
emergence,  curve  over  the  prominence,  and  are  again  concealed  at 
its  edge.  Beyond,  they  have  a  normal  course  and  size  upon  the 
retina.  The  arteries,  where  visible  upon  the  papilla,  are  a  little 
below  the  normal  size  ;  but  beyond,  upon  the  retina,  they  are  much 
smaller  than  normal,  some  being  scarcely  visible  as  mere  lines,  and 
two  cannot  be  detected  beyond  the  edge  of  the  papilla.  There  are  a 
few  very  minute  shining  white  spots  upon  the  centre  of  the  swelling ; 
between  it  and  the  macula  are  several  white  flecks,  and  close  to  the 
macula  a  few  radiating  dots  and  lines  are  arranged  in  a  fan-like 
form.  Vision :  reads  Xo.  6  Jager.  (See  p.  98.) 

FIG.  4. — Subsiding  albuminuric  neuritis.  The  fundus  of  a  patient 
suffering  from  chronic  Brighfs  disease  (probably  granular  kidney),  with 
a  pulse  of  very  high  tension. 

The  papilla  is  slightly  prominent,  greyish-white,  the  edges  of  the  disc 
being  concealed  by  it.  The  veins  are  narrow  and  the  arteries  extremely 
small,  recognizable  only  in  narrow  lines.  One  or  two  small  extra- 
vasations are  seen  near  the  disc,  and  farther  off  are  several  small  col- 
lections of  pigment,  probably  the  remains  of  former  extravasations. 


320  MEDICAL    OPHTHALMOSCOPY. 

PLATE   X. 

FIG.  1. — Acute  nephritic  retinitis,  in  a  patient  suffering  from  chronic 
renal  disease,  consecutive  to  an  acute  attack  twelve  years  previously.  Man 
ayed  twenty-one. 

The  disc  is  veiled  by  a  pale  opacity,  not  prominent,  which  extends 
on  to  the  adjacent  retina.  Many  soft  white  areas  and  striated 
haemorrhages  are  scattered  over  the  posterior  segment  of  the  retina. 
The  veins  are  a  little  larger  than  normal.  Many  of  them  are  much 
concealed  at  the  edge  of  the  papilla.  The  arteries  are  large  and 
conspicuous  over  the  disc,  but  cannot  be  traced  beyond  (probably 
because  they  become  contracted  in  size,  and  are  concealed  by  the 
retinal  opacity).  Vision  7'7.  For  the  microscopical  appearances  see 
Figs.  68,  69,  70,  72. 

FIG.  2. — Chronic  retinal  changes  in  albuminuria,  from  a  case  of  acute 
renal  disease  passing  into  the  chronic  form.  Right  eye.  Woman  aged 
twenty-four. 

The  disc  and  its  central  cup  are  normal.  The  vessels  have  a 
normal  course.  Many  irregular  white  spots  lie  around  the  disc, 
especially  between  it  and  the  macula,  around  which  is  a  halo  of 
small  spots,  for  the  most  part  very  minute ;  one  or  two  larger  and 
very  white.  The  other  spots  are  soft-edged:  some  of  them  are 
superficial  to  the  veins.  There  are  a  few  small  haemorrhages,  most 
of  them  adjacent  to  white  spots.  A  small  vessel  which  passes 
upwards  is  accompanied  by  extravasation,  as  if  into  its  perivascular 
sheath.  Vision  :  reads  No.  12  Jager. 

PLATE  XI. 

FIG.  1. — Retinal  changes  in  a  case  of  progressive  pernicious  anaemia. 
Right  eye.  Man  aged  forty-seven. 

The  general  tint  of  the  fundus  is  paler  than  normal.  The  disc  is 
clear  and  the  vessels  distinct  almost  to  their  origin  in  the  centre. 
The  veins  are  very  broad  and  pale,  scarcely  darker  than  the  arteries. 
Their  central  reflection  is  broad  and  indistinct.  The  arteries  are 
rather  narrower  than  normal,  and  very  narrow  in  proportion  to  the 
veins.  A  large  number  of  striated  haemorrhages  lie  around  the 
papilla.  Many  of  these  are  adjacent  to  vessels,  in  front  of  or  beside 
them,  but  the  course  of  the  vessels  is  not  disturbed.  Some  white 
spots  are  seen,  most  of  which  are  adjacent  to  extravasations,  one  or 
two  being  surrounded  by  a  halo  of  haemorrhage.  One  large  white  spot 
above  the  disc  has  an  irregular  extravasation  below  it,  but  only  a  few 
small  spots  of  blood  above  it.  (See  p.  245.) 

FIG.  2. — Retinal  changes  in  leucocyth&mia.  Right  eye.  Man  aged 
tiventy-seren. 

The  optic  disc  is  clear.  The  course  of  the  vessels  is  normal.  The 
retinal  veins  are  very  broad — at  least  twice  their  normal  width. 
Their  central  reflection  is  in  some  veins  narrow  and  indistinct,  in 


PLATE    X 


PLATE   Xi 


1 


V 


PLATE     XM. 


DESCRIPTION   OF    PLATES.  321 

others  it  is  broad.  The  disproportion  in  size  between  the  arteries 
and  veins  is  thus  very  great.  The  veins  are  exceedingly  pale, 
scarcely  darker  than  the  arteries.  An  annular  zone  of  haemorrhage 
surrounds  the  macula  lutea,  broader  on  the  temporal  than  on  the 
nasal  side.  On  the  latter,  adjacent  to  it,  the  retina  presents  a  grey 
reflection.  Between  this  and  the  disc  is  a  striated  hemorrhage  in 
which  are  one  or  two  white  spots.  On  the  outer  side  of  the  annular 
extravasation  is  a  small,  soft,  white  spot  surrounded  by  a  halo 
of  haemorrhage.  The  extravasation  had  caused  a  corresponding 
central  defect  in  the  field  of  vision.  (Subsequently  the  veins  became 
still  larger  and  more  tortuous  as  in  Fig.  2,  p.  11.) 

PLATE  XII. 

FIG.  1. — Retinal  changes  (perimscular  disease,  aneurisms,  $c.)  in  a 
case  of  chronic  renal  disease.  Right  eye.  Woman  aged  thirty-six. 

The  outline  of  the  optic  disc  can  be  seen  on  the  nasal  (right)  side, 
but  is  not  very  distinct.  Its  temporal  portion  is  concealed  by  a 
white  opacity,  which  extends  on  the  adjacent  retina  towards  the 
macula  lutea.  Near  the  latter  are  a  few  minute  white  spots.  Several 
small  extravasations  are  seen  :  one,  rounded  in  form,  near  the  macula, 
and  another  below,  which  extends  for  a  long  distance  along  the 
course  of  a  small  vessel,  wider  at  parts  than  at  others,  and  in  one 
place  interrupted.  Another  extends,  as  a  linear  extravasation,  along 
the  course  of  a  vein  which  passes  directly  downwards.  Three 
arteries  which  pass  upwards  present  a  peculiar  appearance,  being 
concealed  more  or  less  completely  by  white  bands,  corresponding  in 
width  to  the  vessels.  One,  which  passes  upwards  and  to  the  right 
(in  the  drawing),  is  masked  for  a  considerable  distance  by  such  a 
band,  which  ceases  suddenly,  and,  before  its  termination,  presents 
two  interruptions.  The  vessel  beyond  this  sheath,  and  in  the  inter- 
ruptions, is  seen  to  present  perfectly  normal  characters.  Another 
artery,  which  passes  upwards  and  to  the  left,  is  free  at  its  origin, 
but  just  beyond  the  edge  of  the  disc  is  concealed  by  a  similar  band. 
It  pursues  a  somewhat  wavy  course,  the  lower  parts  of  the  curves 
being  indistinct.  Like  the  other,  the  band  ends  abruptly,  and  the 
vessel  beyond  presents  a  normal  appearance.  Another  artery,  which 
arises  in  the  disc  from  that  last  described,  has  a  similar  white 
sheath  from  its  commencement  to  its  disappearance  behind  a  vein. 
It  emerges  some  distance  beyond,  free.  A  vein  passing  upwards 
presents  peculiar  corkscrew-like  curves.  The  vein  which  passes 
downwards  is  invisible  for  a  short  distance,  beyond  the  extravasation 
just  described,  together  with  its  accompanying  artery.  The  arteries 
are,  for  the  most  part,  otherwise  normal,  but  one,  which  passes 
directly  downwards,  presents,  some  distance  from  the  disc,  several 
— at  least  four — distinct  dilatations,  evidently  minute  aneurisms. 
The  central  reflection  from  the  vessel  broadens  out  in  these  dila- 


322  MEDICAL    OPHTHALMOSCOPY. 

tations.  The  last  one  is  globular,  and  appears  at  first  sight  to 
terminate  the  vessel,  but  closer  inspection  reveals  a  narrow  white 
band  passing  from  it,  which  farther  on  broadens,  and  gives  origin 
to  a  branch  of  an  artery  of  normal  appearance.  Here  and  there  in 
the  retina  are  small  collections  of  pigment.  Vision  :  counts  fingers 
only. 

FIG.  2. — Embolism  of  the  central  artery  of  the  retina,  occurring 
simultaneously  with  an  embolism  of  the  middle  cerebral  artery.  Left 
eye,  indirect  image.  Man  aged  thirty. 

The  drawing  was  made  about  a  fortnight  after  the  occurrence 
of  the  embolism.  The  disc  (previously  veiled  by  opacity)  is  clear 
and  pale  (not  quite  pale  enough  in  the  figure),  the  peripheral  part 
almost,  but  not  quite  so  clear  as  the  central  cup.  Its  edges  are 
sharp.  The  veins  have  a  normal  size  and  course.  Several  of  them, 
however,  disappear  at  the  edge  of  the  disc.  The  arteries  are  filiform 
on  the  disc  and  for  some  distance  beyond.  Some  remain,  as  far  as 
they  can  be  seen,  narrow  (even  to  the  periphery  of  the  retina) ; 
others  become  wider  at  a  distance  from  the  disc  which  varies  in  the 
case  of  different  branches.  From  the  upper  part  of  the  disc  a  white 
opacity  extends  a  short  distance  on  to  the  retina.  A  similar  but 
narrower  white  area  extends  from  the  lower  part  of  the  disc,  being 
evidently  situated  behind  the  level  of  an  artery  ;  it  gradually  widens 
and  becomes  less  intense,  and  is  continuous  with  a  mottled  opacity 
which  occupies  the  region  of  the  macula,  and  is  the  remnant  of  a 
large  white  area  which  at  first  occupied  this  region.  A  branch  of 
an  artery  which  courses  across  the  upper  part  of  this  area  is  evi- 
dently dilated,  and  the  minute  branches  which  come  from  it  are 
abnormally  distinct.  Vision  0. 

For  the  microscopical  appearance  of  the  embolus  in  the  retinal 
artery,  see  Fig.  4,  p.  36. 

FIG.  3. — Partial  embolism  of  the  central  artery  of  the  retina.  Rii/ht 
eye,  direct  image.  Woman  aged  twenty. 

The  disc  is  clear ;  the  central  cup  and  sclerotic  ring  distinct.  The 
veins  are  of  normal  course  and  character.  One  division  of  the  central 
artery,  comprising  the  branches  which  course  downwards  and  to  the 
right  (in  the  figure),  is  perfectly  normal.  The  branches  of  the  other 
division  emerge  from  the  upper  part  of  the  disc.  Of  these,  two 
which  pass  upwards  and  outwards  (to  the  left)  are  completely 
obliterated,  visible  only  for  a  short  distance  as  white  threads.  Two 
others  which  pass  upwards  are  very  narrow,  but  the  central  reflection 
can  just  be  distinguished.  One  of  them  is  accompanied  for  a  short 
distance  by  fine  white  lines  along  its  sides.  Both  vessels,  some 
distance  from  the  disc,  become  wider  and  resume  their  normal 
appearance ;  a  branch  of  one  which  passes  to  the  right  remains 
filiform  throughout.  No  changes  visible  in  the  neighbourhood  of 
the  macula.  Vision :  the  field  presented  a  defect  corresponding 
to  the  area  supplied  by  the  obstructed  vessels.  (See  Fig.  5,  p.  39.) 


INDEX. 


The  Index  does  not  contain   references  to   the  Description  of  the  Plates.       The 
subjects  of  these  arc  enumerated  in  the  Table  of  Contents. 


Abscess  of  bi'ain,  155 
Ague,  284 
Albuminuria,  208 
Albuminuric  retinitis,  212 
Alcoholism,  chronic,  273 

acute,  275 
Amaurosis,  epileptiform,  22 

saturnine,  269 

unemic,  209 
Amblyopia  in  alcoholism,  273 

diabetes,  228 

mercury  poisoning,  279 

silver  poisoning,  279 

tobacco  poisoning,  275 
Anastomoses  of  retinal  artery,  37 
Ansemia,  acute,  236 

chronic,  11,  242 

of  brain,  137 

pernicious,  244 

scorbutic,  246 

of  retinal  vessels,  22 
Aneurism,  intra-cranial,  168 

of  internal  carotid,  169 

of  retinal  arteries,  15 
capillary,  16 
miliary,  16 

in  Bright's  disease,  211 
cerebral  hfemorrhage,  142 
diabetes,  230 

Aortic  regurgitation,  19,  233 
Artery,  internal  carotid,  aneurism,  168    j 
thrombosis,  32,  153 


Artery,  ophthalmic,  32 
Arteries,  retinal,  7 
aneurism,  15 
dilatation,  12 
embolism,  33 
narrowing  of,  11 
thrombosis,  32 
variations  in  size,  8,  22 

(See  also  "Vessels,  retinal.") 
Argyria,  279 
Ataxy,  locomotor,  190 
Atrophy  of  optic  nerve,  102 
causes,  110 
characters,  103 
choroiditic,  110 
congestion  preceding,  107 
consecutive,  57,  102 

characters,  108 

pathological  anatomy,  118 

prognosis,  130 

symptoms,  127 
diagnosis,  128 
from  damage  to  retina,  115 
pathological  anatomy,  116 
primary,  111 
prognosis,  130 
retinitic,  115 
secondary,  113 
simple,  102 
spinal,  111 
symptoms,  119 

in  relation  to  form,  123 


324 


MEDICAL    OPHTHALMOSCOPY. 


Atrophy  of  optic  nerve,  treatment,  131 
in  alcoholism,  273 
in  cerebral  haemorrhage,  146 

softening,  150,  153 

tumour,  166 

cerebro-spinal  meningitis,  178 
chronic  alcoholism,  273 

hydrocephalus,  169 
diabetes  mellitus,  228 

insipidus,  232 
diphtheria,  290 
erysipelas,  288 

gastro-intestinal  disorders,  255 
general  paralysis,  205 
hydrocephalus,  169 
hysteria,  204 
injuries  to  the  head,  184 
insular  sclerosis,  196 
labio-glossal  paralysis,  168 
lateral  sclerosis,  195 
lead  poisoning,  270 
locomotor  ataxy,  190 

anatomical  characters,  193 

symptoms,  193 
loss  of  blood,  239 
malarial  fevers,  287 
neuralgia,  200 
scarlet  fever,  283 
small-pox,  284 
syphilis,  264 
tobacco  poisoning,  277 
tubercular  meningitis,  175 
typhoid  fever,  280 
typhus  fever,  279 
Atropine,  use  and  dangers  of,  2 
Axial  neuritis,  123 
in  diabetes,  228 

spinal  disease,  125 

Bed,  examination  of  patients  in,  3 
Bisulphide  of  carbon,  poisoning  by,  278 
Blind  spot,  in  neuritis,  70 
Blood,  diseases  of  the,  236 

loss  of,  effect  on  retinal  vessels,  19 

amaurosis  from,  237 
Bones,  cranial,  diseases  of,  179 

caries,  179 

necrosis,  187 


Bones,  cranial,  thickening,  180 
Brain,  abscess  of,  155 

anaemia  of,  139 

compression  of,  186 

diseases  of,  137 

hydatid  disease  of,  167 

hyperfemia  of,  138 

inflammation  of,  140 

injuries  to,  184 

softening  of,  146 
(See  "Softening.") 

tumours  of,  156 
Bright's  disease,  208 

arteries  in,  12,  209 

optic  neuritis  in,  96,  217 

retinal  changes  in,  212 

(See  "  Retinitis.") 
Bronchitis,  254 

putrid,  294 
Bulbar  paralysis,  168 

Capillaries,  retinal,  aneurisms  of,  17 
in  Bright's  disease,  211 
in  diabetes,  230 
varicose,  17 
Capillary  pulsation,  20 
Carbon,  bisulphide  of,  poisoning  by,  278 
Cavernous  sinus,  thrombosis  in,  154 

pressure  on,  79 
Cerebellum,  abscess  of,  156 
Cerebral  ansemia,  139 

circulation,  relation  of  retinal  to, 

18,  137 

congestion,  138 
haemorrhage,  142 
softening,  146 

from  atheroma,  152 
embolism,  146 
syphilitic  disease,  150 
(See  also  "  Brain.") 
Cerebritis,  chronic,  140 
Chiasma,  optic,  effects  of  pressure  on,  72 

a  cause  of  atrophy,  114 
Chlorosis,  242 
Choked  disc,  48,  79,  89 
Cholera,  23,  291 
Chorea,  198 
Choroid,  morbid  states  of,  135 


INDEX. 


325 


Choroid,  morbid  states  of,  in  Bright's 

disease,  221 
in  leucocythtemia,  253 
tubercles  in,  258 
Choroidal  arteries,  degeneration,  136 

embolism,  136 
haemorrhage,  30 
in  endocarditis,  235 

purpura,  253 
Choroiditic  atrophy,  115 
Choroiditis,  syphilitic,  264 
Circulation,  retinal,  18 
obstruction  to,  24 
Colour-vision,  affection  of,  in  atrophy, 

120 

diabetes,  228 
chronic  alcoholism,  273 
lead  poisoning,  270 
neuritis,  71 
tobacco  poisoning,  276 
Congestion  of  brain,  138 
of  optic  disc,  44 
in  alcoholism,  274 
caries  of  spine,  196 
cerebral  softening,  147 
chronic  alcoholism,  274 
diphtheria,  289 
general  paralysis,  207 
lead  poisoning,  270 
mania,  207 
parotitis,  290 
tobacco  poisoning,  277 
with  oadema,  46 
Constipation  and  retinal  haemorrhage, 

255 

Cough,  effect  on  retinal  circulation,  29 
Cranial  bones,  diseases  of,  179 

caries,  179 
thickening,  180 
Cyanosis,  233 
Cysts  in  brain,  167 

Daylight,  examination  in,  4 
Death,  ophthalmoscopic  signs  of,  297 
Dementia,  208 
Diabetes  mellitus,  227 

insipidus,  232 
Diarrhoea,  255 


Digestive  organs,  diseases  of,  255 
Diphtheria,  289 
Disc,  optic,  appearance  of,  41 
congestion,  44 
causes,  46 
with  oedema,  46 
inflammation,  48 
structure,  41 

variations  in  colour,  4,  44 
vessels  of,  4 

(See  also  "Nerve,  optic.") 

Electricity,  sensitiveness  of  retina  to, 

in  neuritis,  72 
treatment  of  atrophy,  132 
Embolism  of  cerebral  arteries,  34,  146 
of  middle  meningeal,  a  cause  of 

atrophy,  114,  150 
of  retinal  artery,  33 
appearances,  34 
symptoms,  39 
in  Bright's  disease,  223 
cerebral  embolism,  146 
chorea,  198 
heart  disease,  234 
typhoid  fever,  281 
capillary,   of  retina,    in   pyaemia, 

292 

Emphysema  of  lungs,  254 
Encephalitis,  chronic,  140 
Endocarditis,  malignant,  234 

septic,  295 
Epilepsy,  201 
Erysipelas,  288 
Eserine,  use  of,  2 
Examination,  methods  of,  2 
Excavation  of  optic  disc,  normal,  41 

in  atrophy,  105 
Exophthalmic  goitre,  198 

Fever  (see  "Relapsing,"   "  Typhoid, 

"Typhus,"  "Scarlet.") 
Field  of  vision — 

in  anremic  amaurosis,  238 
alcoholism,  273 
atrophy,  119,  123 
quinine  poisoning,  278 
neuritis,  69 


326 


MEDICAL    OPHTHALMOSCOPY. 


Field  of  vision,  in  tobacco  poisoning,  276 

for  colours,  120 
Films  over  vessels,  6 
Foramen,  optic,  narrowing  of,  180 
Fundus,  how  to  sketch,  299 

General  paralysis  of  the  insane,  205 
Glaucoma,   haemorrhagic,    in    albumi- 

nuria,  223 
in  diabetes,  230 
leucocythaemia,  252 
neuralgia,  201 

Glioma,  mistaken  for  cerebral  haemor- 
rhage, 145 
for  softening,  149 
Goitre,  exophthalmic,  198 
Gout,  267 

Growths  in  the  brain,  156 
in  the  eye,  156 

(See  also  "  Tumours.") 

Haematoma  of  dura  mater,  177 
Hemorrhage,  general,  236 
cerebral,  142 

indication  of,  how  transmitted, 

152 

in  optic  nerve,  50 
into  optic  nerve-sheath,  145 
meningeal,  145 
retinal,  25 
symptoms,  27 
causes,  28 
in  ague,  284 

Bright's  disease,  211 

bronchitis,  254 

cerebral  haemorrhage,  142 

softening,  148 
endocarditis,  234 
gout,  267 

leucocythaemia,  249 
malarial  fevers,  284 
meningeal  haemorrhage,  145 
meningitis,  purulent,  172 

tubercular,  175 
pernicious  anaemia,  245 
purpura,  253 
optic  neuritis,  52 
scurvy,  254 


Haemorrhage,  retinal, in  septicaemia,  294 

into  vitreous  in  Bright's  disease, 

223 

Htemorrhagic  pachy meningitis,  177 
Haller,  circle  of,  41 
Head,  injuries  to,  183 
Heart,  diseases  of,  232 
Heatstroke,  188 

Hemianaesthesia  in  lead  poisoning,  269 

Hemianopia  from  cerebral  disease,  72 

pressure  on  chiasma,  72 

state  of  optic  nerve  in,  114 
Hemi-neuritis,  50 
Hernia  cerebri,  187 
Hydatid  cysts  in  brain,  167 
Hydrocephalus,  chronic,  170 

atrophy  in,  169 

Hyperajmia  of  retinal  vessels,  24 
Hypermetropia,  neuritis  in,  99 

recognition  of,  3 
Hysteria,  204 
Hystero-epilepsy,  204 

Injuries  to  head,  183 

to  spine,  197 

Insane,  general  paralysis  of,  205 
Insanity,  204 
Insolation,  138,  188 
Isohaemia,  retinal,  22 

Jaundice,  255 

Kidneys,  diseases  of,  208 
Knee-jerk,   absence  with   optic   nerve 
atrophy,  192 

Labio-glossal  paralysis,  168 
Lardaceous  kidney,  retinitis  with.  212 
Lead-poisoning,  269 
Leucocythaemia,  247 

retinal  veins  in,  11,  248 
Locomotor  ataxy,  190 
Lungs,  diseases  of,  254 

Malarial  fevers,  284 

Mania,  207 

Measles,  282 

Melancholia,  208 

Meninges,  haemorrhage  into,  145 


INDEX. 


327 


Meninges,  growths  in,  170 
Meningitis,  171 

cerebro-spinal,  epidemic,  178 
simple,  172 

chronic,  172 

in  cerebral  tumour,  159 
meningeal  growths,  171 
septicaemia,  297 

purulent,  172 

simple,  172 

syphilitic,  177 

traumatic,  178,  186 

tubercular,  173 
Menstrual  disorders,  256 
Mercurial  poisoning,  279 
Migraine,  200 
Miliary  abscesses  in  optic  tracts,  67 

aneurisms  in  retina,  16 
Mumps,  290 
Myelitis,  189 

Nerve  fibres,  opaque,  5 
Nerve,  optic,  atrophy  of,  102 

(See  "  Atrophy.") 
changes  in,  42 
congestion,  44 
inflammation,  48 

(See  "Neuritis.") 
injuries  of,  185 
morbid  states  of,  43 
trunk  of,  changes  in,  66 
sheath  of,  42 

(See  "Sheath.") 
Nervous  system,  diseases  of,  137 

functional,  198 
Neuralgia,  200 
Neuritis,  optic,  48 

descending,  48,  78,  83 
frequency,  89 
in  cerebral  tumour,  156 

tubercular  meningitis,  173 
intra-ocular  (papillitis),  48 
causes,  75 

recognition  of,  96 
diagnosis,  94 
duration,  76 

pathological  anatomy,  57 
prognosis,  100 


Neuritis,  intra-ocular,  primary,  82 

relation  to  encephalic  disease,  78 

second  attacks,  57 

stages,  49 

subsidence,  54 

anatomical  change  during,  67 

symptoms,  67 

treatment,  100 

unilateral,  161 

varieties,  92 
in  alcoholism,  274 
anaemia,  acute,  239 

chronic,  243 

pernicious,  245 

aneurism  of  internal  carotid,  168 
Bright's  disease,  98,  217 
caries  of  sphenoid  bone,  179 
cerebral  abscess,  155 

haemorrhage,  144 

softening,  147 

tumour,  75,  156 
cerebritis,  141 
chorea,  199 
general  paralysis,  207 
heatstroke,  188 
hydatid  disease  of  brain,  167 
hydrocephalus,  169 
injuries  to  the  head,  183 

spine,  197 

lead  poisoning,  99,  271 
loss  of  blood,  239 
malarial  fever,  287 
measles,  282 
meningeal  haemorrhage,  145 

tumours,  170 
meningitis,  172 

tubercular,  174 
menstrual  disorders,  256 
myelitis,  189 
nasal  disease,  187 
orbital  disease,  181 
scarlet  fever,  283 
syphilis,  264 
tumour  of  brain,  156 

course,  161 

significance,  164 
typhoid  fever,  280 
typhus  fever,  280 


328 


MEDICAL    OPHTHALMOSCOPY. 


Neuritis,  retro-ocular,  93 
axial,  94 

(See  "Axial.") 
from  orbital  disease,  115 
Neuro-retinitis, 

(See  "Neuritis.") 
Nose,  diseases  of,  187 

(Edema  of  optic  papilla,  46 

in  tubercular  meningitis,  174 
of  retina  in  Bright's  disease,  220 
in  alcoholism,  274 
in  leucocythsemia,  250 
Opaque  nerve  fibres,  5 
Ophthalmia,  pyjemic,  292 
Ophthalmic  artery,  thrombosis  in,  32, 

154 

Ophthalmoscope,  use  of,  in  medicine,  1 
Ophthalmoscopy,  medical,  objects,  1 
Orbit,  diseases  of,  180 
haemorrhage  into,  182 
inflammation,  180 
injuries,  185 
tumours,  183 

Pachymeningitis,  hremorrhagic,  177 
Pallor  of  optic  disc  in  anaemia,  242 

in  atrophy,  103 
Papilla,  optic,  42 

estimation  of  prominence,  95 

(See  "Nerve,  optic.") 
Papillitis,  43,  48 

(See  also  "  Neuritis.") 

(See  "Atrophy,  consecutive.") 
Papillitic  atrophy,  55,  108 
Paralysis,  general,  of  the  insane,  205 
Parotitis,  290 
Perineuritis,   51 

retro-ocular,  94 
Perivascular  changes  in  retina,  15 

in  Bright's  disease,  211 
Pernicious  anaemia,  244 
Phlegtnasia  dolens,  236 
Phthisis,  254 
Plethora,  236 
Plumbism,  269 

Pregnancy,  affections  of  sight  in,  256 
Pressure,  intra-cranial,  relation  to  optic 
neuritis,  8-'? 


Pressure,    intra-ocular,     influence    on 

circulation,  18 

on  apparent  size  of  vessels,  11 
Pulsation  of  retinal  vessels — 
arterial,  18 

in  exophthalmic  goitre,  198 

neuritis,  50 
capillary,  20 
veins,  20 

rhythmical,  22 
Purpura.  253 
Pyaemia,  291 

Quinine  poisoning,  277 

Reflex  theory  of  optic  neuritis,  81,  91 
Refraction,  estimation  of,  3 
Relapsing  fever,  281 
Retina,  affection  in  neuritis,  56 

tubercular  meningitis,  173,  175 
aneurisms  in,  16 
detachment  of,  in  Bright's  disease, 

222 

growths  in,  132 
haemorrhage  in,  25 
morbid  states  of,  132 
vessels  of,  7 

(See  "  Vessels.") 
white  spots  in,  133 
Retinitis,  albuminuric,  212 

anatomical  changes,  219 
complications,  222 
course,  223 

degenerative  form,  215 
diagnosis,  224 
forms,  214 

hiemorrhagic,  216 
inflammatory,  216 
neuritic,  217 
pathology,  222    , 
prognosis,  227 
symptoms,  221 
treatment,  227 
diabetic,  229 
from  loss  of  blood,  239 
haemorrhagic,  28 
leucocythoemic,  248 
pigtnentosa,  135,  266 


INDEX. 


329 


Retinitis,  septic,  293 

syphilitic,  264 
Rheumatism,  acute,  284 

chronic,  267 

Salicylic  acid  poisoning,  279 
Scarlet,  fever,  282 
Sclerosis  of  cord,  insular,  195 
lateral.  195 
posterior,  190 
of  optic  nerve,  195 
Scotoma,  central,  125 
in  alcoholism,  274 
diabetes,  228 
tobacco  poisoning,  276 
Scurvy,  254 
Septicaemia,  291 
Sexual  organs,  diseases  of,  256 
Sheath  of  optic  nerve,  42 
communication,  80 
distension  of,  66,  80 
effect  on  veins,  10 
relation  to  neuritis,  80,  86 
to    excess    of   sub-arachnoid 

fluid,  86 

tubercles  in,  176,  262 
haemorrhage    into,   in    meningeal 

haemorrhage,  145 

Sight,  how  affected -in  atrophy,  119 
in  neuritis,  68 

intra-cranial  disease,  69,  72 
Silver  poisoning,  279 
Sinus,    cavernous,    effects  of  pressure 

on,  78 

Skin,  diseases  of  the,  257 
Skull,  fracture  of  the,  185 
Small-pox,  284 
Softening  of  brain,  146 
chronic,  155 
embolic,  146 
inflammatory,  154 
primary,  154 
thrombotic,  150 
Spinal     cord,    connection     of    ocular 

changes  with,  112 
diseases  of,  189 

(See    also    "Sclerosis"     and 
"  Myelitis.") 


Spine,  caries  of,  196 

injuries  to,  197 
Staphyloma,  posterior,  5 
Stauungs-papille,  48,  79 
Stomach,  diseases  of,  255 
Strangulation  in  optic  neuritis,  52 

in  descending  form,  83 

mechanism,  84 
Sunstroke,  188 

Syncope,  retinal  vessels  in,  23,  139 
Syphilis,  263 

inherited,  265 

Syphilitic  diseases  of  cerebral  vessels, 
150 

Tension,     intra-ocular,     influence     on 

circulation,  18 

Thrombosis  in  cerebral  vessels,  150 
internal  carotid,  32,  153 
ophthalmic  artery,  32,  154 
retinal  vein,  30 
retinal  artery,  32 
Tissue,  white,  in  front  of  disc,  6 
Tobacco  poisoning,  275 
Tonsillitis,  290 
Tracts,    optic,    changes    in    atrophy, 

118 

in  neuritis,  67 
Tubercles  of  choroid,  258 

in  tubercular  meningitis,  173 
of  optic  nerve,  261 

retina,  262 

Tubercular  meningitis,  173 
Tuberculosis,  257 
Tumour  of  brain,  156 

associated  growth  in  eye,  156 
atrophy  in,  166 
neuritis  in,  75,  156 
of  meninges,  170 
Typhoid  fever,  280 

diagnosis  from  septicaemia,  297 
Typhus  fever,  279 

Uremia,  208 

Urinary  system,  diseases  of,  208 

Variola,  284 

Vaso-motor  theory  of  neuritis,  SI,  91 


330 


MEDICAL   OPHTHALMOSCOPE. 


Vein,  central,  thrombosis  in,  30 

orbital,       communication       with 

facial,  79 

Veins,  retinal,  atony  of.  10 
dilatation  of,  10 
diminution  in  size  of,  1 1 
increased  width  of,  9 
in  anaemia,  11,  242 
cyanosis,  233 
death,  298 

leucocytheemia,  11,  248 
neuritis,  51,  52 
pulsation  in,  20 
thrombosis  in,  30 
varicose,  10 

Venesection,  effect  on  blood,  23 
Vessels,  diseases  of,  235 
Vessels,  retinal,  anaemia  of,  22 
arrangement,  12 
atheroma,  15 
calcification,  15 
congestion,  passive,  24 
course,  13 
degeneration,  15 
hypersemia  of,  24 
in  atrophy,  107 

Bright's  disease,  209 


Vessels,    retinal,    in   convulsions,    22, 

201 

malarial  fever,  286 
neuritis,  52 
quinine  poisoning,  278 
pulsation  ia,  18 
rupture,  25 
sclerosis  of,  14 
size,  8 

variations  in,  9 
structural  changes,  13 
tissue  around,  14 
wall  of,  thickened,  14 
visibility,  7 

(Sec  also  "  Arteries.' ) 
Vision  (see  "Sight,"  "Field"). 

colour  (see  "  Colour  vision  "). 
Vitreous,  haemorrhage  into,  26 

in  Bright's  disease,  211,  223 
diabetes,  230 

opacity  of,  in  diabetes,  230 
in  pyaemia,  292 

White  spots  near  disc,  5 
Whooping-cough,  290 

Xanthelasma,  201 


OTHER   WORKS  BY  DR.  GO  WEES,  F.R.S. 


EPILEPSY     AND     OTHER     CHRONIC     CONVULSIVE 

DISEASES:   THEIR  CAUSES,  SYMPTOMS,  AND  TREATMENT.     Svo. 

PSEUDO-HYPERTROPHIC    MUSCULAR    PARALYSIS. 

A  Clinical  Lecture.     With  Engravings.     Svo. 

DIAGNOSIS  OF  DISEASES    OF    THE   SPINAL   CORD. 

With  Engravings.     Third  Edition.     Svo. 

DIAGNOSIS  OF  DISEASES  OF  THE  BRAIN.     Lectures 

delivered   at   University    College    Hospital.      Second    Edition.      With 
Engravings.     Svo. 

A  MANUAL  OF  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Vol.  I.    DISEASES  OF  THE  SPINAL  CORD  AND  NERVES.    With  Engravings. 
Royal  Svo. 

Vol.  II.  DISEASES  OF   THE  BRAIX    AND    CRANIAL  NERVES;    GENERAL 
AKD  FUNCTIONAL  DISEASES.     With  Engravings.     Svo. 


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